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The introduction of Primary Health Care (PHC) in Saudi Arabia has given nurses excellent opportunities and more responsibility to provide health education and advice in health promotion activities. Provision of appropriate and affordable dietary advice is an important role of the nurses in the Primary Health Care Centres (PHCC). Maternal nutrition is an essential element for the health status of the child, the family and the wider society. Many studies have suggested that there is a relationship between good nutritional intake during pregnancy and the successful outcome of the pregnancy. The present study was conducted to explore the knowledge and understanding of Saudi women and nurses in PHCC regarding nutritional intake during pregnancy. The study also looked at the effect of a short education programme on the nurses' nutritional knowledge and their subsequent practice. The aims of the study were to identify the understanding of Saudi women of pregnancy and nutritional intake during pregnancy, and to evaluate the effect of a short nutritional programme on diploma nurses. To achieve the aims, data collection was carried out in three phases. Phase one used semi-structured interview (tape recorded) on 10 pregnant women, selected randomly, to elicit the general understanding pregnant women had on pregnancy and pregnancy related areas. Phase two used a structured interview schedule on 100 pregnant women attending PHCC, selected systematically, to assess nutritional knowledge and their perception of nutritional advice given by the nurses in PHCC. Phase three was divided into two stages. The first stage used a self-administered questionnaire on 20 diploma nurses working in antenatal clinics in PHCC to assess their nutritional knowledge in relation to pregnancy. The questionnaire was used as both a pre-test and post-test instrument. Thereafter, based on the findings from phase one and two, a 20-hour continuing education (CE) programme was developed by the researcher on maternal nutrition for the diploma nurses. The second stage was to implement the programme to the nurses in five days. The effect of the programme was evaluated by an immediate post-test on nurses' knowledge and a follow-up post-test (after six months) to assess any lasting changes. Data analysis was carried out using content analysis for phase one. For the phase two and three, SPSS programme was used. Chi square was used to look for any association between knowledge scores and personal variables, paired Hest was used to assess the difference between pre-test and post-test. The results from the study showed that the majority of women attending the PHCC were illiterate or had little formal education, had a high pregnancy rate and had poor nutritional knowledge in relation to pregnancy. They preferred female health professional care and they preferred to have female doctors attending their antenatal care rather than the nurses. There was no significant difference between nurses' and women's nutritional knowledge. The results also showed a significant correlation between poor nutritional knowledge scores of the women and certain factors: the scores correlated positively with the level of education and negatively with the number of pregnancies. Regarding the programme, the results showed a significant increase in the nurses' nutritional knowledge scores from pre-test to post-test at p< 0.05, indicating that participants demonstrated increased nutritional knowledge as a result of participation in the programme. There was no significant difference between the initial post-test and the six-month follow-up. No significant relationships were identified between the nurses' scores and their age and years of experiences. The study also indicated that nurses in PHCC were not giving adequate nutritional advice to pregnant women in the views of these women and in my own observation. The findings suggest that frequent continuing education is essential for nurses in PHCC in Saudi Arabia to improve their skills and nutritional knowledge to be able to provide better care for women.

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WIC food packages are undergoing major revisions to accommodate the unique requirements of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in the twenty-first century. This dissertation is an evaluation of the impact of the revised WIC food packages through national-level surveys obtaining data before and after food package changes. In addition, a community-level metabolic/dietary study of obese women consuming either the original or revised food packages was performed. Since WIC has never revamped its entire program before, this is an opportunity to learn more about the impact of the revisions on WIC participants across the country, including Native Americans from Indian Tribal Organizations (ITOs). The National Food and Nutrition food frequency questionnaire (NATFAN) evaluates food and consumption practices of WIC participants, including Native Americans, for both the original and revised WIC food packages. The baseline surveys (NATFAN') were administered before the 2009 rollout of the revised WIC food packages (dates varied by state program). The post-rollout surveys (NATFAN'') were administered spring through winter of 2010-2011, and at least six months after the implementation of the revised WIC food packages. Hierarchical linear modeling, with restricted maximum likelihood approximation, was used to evaluate 100% juice, fruit, and vegetable frequency of consumption based upon NATFAN' and NATFAN'', including samples from states, territories, and ITOs. This research is important because it was national in scope and analyzed nutritional behaviors of a Native American subpopulation of WIC that is seldom documented in national nutrition research. For the metabolic/diet study, obese women 185% of the poverty level were given the original or revised WIC food packages (n=3). Three venous blood serum collections (0, 6, 12 weeks) were biomarker tested (cholesterol, glucose, C-reactive protein, etc.) in lipid and metabolic panels. Three, seventy-two hour dietary recalls were also assessed to determine fruit and vegetable consumption changes over the course of the study. This phase was important because it focused on the individual's actual consumption behaviors of specific WIC foods dispensed in the WIC food packages and assessed how such consumption affected the health of the individual.

Maternal obesity is a key predictor of childhood obesity. It has been shown to cause changes in maternal adaptation to pregnancy that result in an adverse in utero environment, inducing increased risk of obesity and metabolic disease in the offspring. Perturbation of gut microbiota over the course of pregnancy has been implicated in maternal metabolic adaptations. We investigated how high-fat (HF) diet-induced obesity before and during pregnancy affects gut microbiota and maternal intestinal barrier function, and whether altered maternal gut adaptations to pregnancy influence placental development. Microbiota of HF mice was modified by diet, and further modulated by pregnancy. Changes in mucin-degrading and short chain fatty acid (SCFA) producing bacteria were found in microbiota from HF pregnant mice. SCFA receptor, GPR41, expression was reduced in the duodenum and jejunum of HF dams. Intestinal barrier function was impaired in HF pregnancies as indicated by increased paracellular intestinal permeability measured by passage of FITC-Dextran and increased concentration of bacterial lipopolysaccharide in the maternal serum, observations that were consistent with reduced gene expression of tight junction proteins in the small intestine of HF dams. Diet-induced maternal obesity altered gene expression of inflammatory and immune cell marker genes in different gut sections. However, no change in TNF and IL-6 in maternal serum suggested that HF diet-induced obesity was not associated with systemic maternal inflammation. Female placenta from HF pregnancies were smaller in size, as calculated by measuring the cross sectional area of the placenta, which may be regulated by increased apoptosis. Augmented placental inflammation was not observed in HF placentas. Changes in maternal intestinal adaptations appear to be modified by diet-induced obesity before and during pregnancy, in a manner that reduced maternal barrier function and increased intestinal immune cell markers but these changes appeared not be associated with placental pro-inflammatory status. / Thesis / Master of Science (MSc)

Maternal nutrition, breast milk micronutrients and infant growth in rural Gambia The World Health Organization recommends exclusive breastfeeding for the first six months of an infant’s life. However, the evidence base to support the adequacy of breast milk with respect to infant micronutrient status, across the duration of exclusive breastfeeding, among women who enter pregnancy and lactation with a poor nutritional status is limited. The research presented in this thesis explores the relationship between maternal nutritional status, breast milk micronutrients and infant status in a rural sub-Saharan context. Existing evidence for associations between maternal dietary intake and nutritional status and breast milk micronutrient composition were systematically reviewed. Most effected by maternal nutrition were breast milk water-soluble vitamin concentrations (except for folic acid), fat-soluble vitamin concentrations were less influenced, and mineral concentrations were generally unaffected (except for iodine and selenium). Next, the impact of feeding practice on infant growth in rural Gambia was explored. In this population, where growth faltering across the first two years of life is endemic, exclusive breastfeeding to six months of age had limited benefit on infant growth. Finally, the impact of maternal multiple micronutrient supplementation on breast milk iodine, thiamin, riboflavin, vitamin B6 and B12 was explored. Supplementation during pregnancy positively influenced maternal status for all investigated micronutrients, and modestly increased breast milk iodine and riboflavin concentrations across the first six months of lactation. No effects on breast milk concentrations of thiamin, vitamin B6 or B12, and limited effect on infant postpartum status, were observed. The research presented in this thesis suggests that concentrations of breast milk micronutrients may be insufficient in settings where maternal micronutrient status is poor, with likely consequences for infant health. This research supports the need for interventions to improve the nutritional status of pregnant and lactating women in resource-poor settings alongside the promotion of exclusive breastfeeding for optimal health outcomes for infants as well as their mothers.

Background: The number of women considered overweight (OW) and obese (OB) in Canada has steadily increased over the past thirty years. In addition, there has also been a rise in the amount of weight women gain during pregnancy. Many adverse pregnancy outcomes are associated with maternal overweight, obesity and/or excessive gestational weight gain (GWG), which have been widely studied and reported. In 2009, the Institute of Medicine (IOM) developed healthy GWG guidelines, based on trial and observational evidence, that provide BMI-related weight gain targets. This evidence has shown that weight gain within the guidelines results in better health outcomes for the mother and baby, during pregnancy, as well as postpartum. Objectives: (1) To address diet quality and patterns using data collected from the Maternal Obesity Management (MOM) Intervention Trial, and (2) Develop and validate a comprehensive web-based questionnaire that can be used in a future study to examine women’s knowledge of the IOM GWG guidelines, dietary recommendations, physical activity (PA) practices, as well as other lifestyle habits. Methods: (1) Exploratory pooled analysis of dietary data from Maternal Obesity Management (MOM) trial - To identify diet quality of women who exceeded (EX) versus did not exceed (NEX) the 2009 IOM pregnancy weight gain targets. Participants (n=50) completed 7-day food records at 3 points during pregnancy (baseline (V1: 12-20 weeks), between 26-28 weeks (V2) and between, 36-40 weeks (V3). Data were analyzed in ESHA Food Processor Program and SPSS (version 13) to see if there was any difference found in diet between EX and NEX women. (2) Development and validation of a comprehensive maternal health questionnaire aimed to establish gaps in women’s behaviours and perceptions of the IOM GWG guidelines - An expert panel was consulted in the development of questionnaire constructs and items to gain content validity of the questionnaire. After multiple phases of questionnaire development and revisions, a 14-day test re-test validation pilot study was conducted to establish test re-test validity. Results: (1) In the EX and NEX analysis, significant decreases were found in total energy intake, including fat and protein, across pregnancy in the NEX GWG group. Significant group-by-time interaction was also found for energy intake and protein. (2) Most constructs included in the electronic maternal (EMat) Health questionnaire all proved to have sufficient test re-test validity via correlation analysis. Conclusion: In order to address the knowledge gaps regarding excess weight and changes in dietary habits during pregnancy, it is beneficial to explore pregnant women's knowledge and behaviours regarding these issues and collect information on what women report as barriers and facilitators to gestational weight management. The conclusions drawn from both of these studies may inform future interventions, as well as indicate where further education strategies are needed.

Introduction: Short- and long-term health outcomes of children stem from their first 1000 days of development (3 months prior to conception to 2 years postpartum). Research shows a correlation between poor maternal nutrition and adverse birth outcomes. Various factors such as human breast milk (HBM), gut microbiome (GM), and body mass index (BMI) correlate with nutrition. The purpose of this study was to determine if maternal factors such as BMI impact preterm infant microbiome and short chain fatty acid (SCFA) profiles. Methods: Sample Collection: In order to understand the effect of maternal health factors on neonatal GM, deidentified stool samples were collected from the NICU at the MUSC and were utilized for GM and SCFA analysis at ETSU. Microbiome Analysis: GM analysis was performed on stool samples using the Qiagen QIAmp PowerFecal Pro DNA Kit. DNA was sequenced using Amplicon sequence of the 16s rRNA region with a modified Klindworth et al method. GM was analyzed using CLC Genomics Workbench v. 23 where Alpha diversity indexes were calculated with the Abundance Analysis tool and the Beta diversity (inter-sample diversity) was calculated using the weighted Unifrac metric. Short Chain Fatty Acid Analysis: The stool samples were subjected to SCFA extraction and analysis via a modified Schwiertz et al. method. Results: Significance was observed between the groups in microbiome for; C-section (yes, no), gestation (<28, 28-32, 33-36 weeks), week of sample collection (1, 2, 3, 4, >4 weeks), and maternal BMI + antibiotics (no antibiotics + normal, overweight, or obese BMI and antibiotics + normal, overweight, or obese BMI). Significance was detected between the groups in fecal fermentation for; recreational drug use (use, no use), preeclampsia (preeclamptic, not), sepsis evaluation (yes, no), week of sample collection (1, 2, 3, 4, >4 weeks), and Fenton measurements for birth length, birth weight, and occipital frontal circumference (small, average, large for gestational age). Conclusions: These results provide valuable insights into the various maternal and neonatal factors on the GM and SCFA profiles of preterm infants, which can have implications for their overall health and development. It is possible for future adverse health outcomes of premature neonates to be attenuated through HBM ingested and GM.

The intrauterine environment induces developmental adaptations that impact health and disease risk later in life. Reproductive abnormalities are now included in the long list of health complications seen in offspring exposed to early life adversity including poor prenatal nutrition. Previous work has shown using a rat model, that offspring born to mothers that were nutrient restricted (UN) during pregnancy are growth restricted, enter puberty early, and as adults, display characteristics of early ovarian aging with reduced follicle number. This present study aimed to investigate whether key proteins involved in ovarian follicle recruitment and growth, including the PI3K/Akt pathway, may be impaired as a result of early life nutritional adversity. Maternal UN resulted in irregular estrous cyclicity due to persistent estrus, a significant decrease in young adult ovarian antral follicles, corpora lutea, and a significant increase in atretic follicles. A decrease in growing follicles in UN offspring appears to be due to lowered expression of granulosa-cell secreted growth factor IGF-1 in antral follicles, and increased expression of pro-apoptotic factor Casp3 in secondary follicles of young adult offspring born to UN dams. Changes in follicle signalling pathways were apparent before observing altered ovarian function. In UN prepubertal offspring, expression levels of IGF1-R and FSHR were lowered in secondary and antral follicles respectively. These growth factors may contribute to a decrease in PI3K/Akt activation as immunohistochemical staining revealed a decrease in pAkt immunolocalization in prepubertal antral follicles. Moreover, neonatal ovaries of UN offspring show decreased levels of immunopositive staining for AMHRII, a regulatory receptor of the ovarian reserve. This study demonstrates that maternal UN during pregnancy impacts ovarian function in female offspring as early as P65. Findings from this study provides a model of understanding mechanisms of follicle loss and reproductive dysfunction as a result of nutrient restriction during fetal life. / Thesis / Master of Science (MSc)

This thesis consists of three manuscripts, which are presented in chapters 2, 3 and 4. The first manuscript (chapter 2) is a protocol for systematic review which outlines the steps used to systematically analyze the literature with regards to the primary objective of reviewing available evidence. The second manuscript (chapter 3) is the presentation of systematic review and meta-analysis in the form of a manuscript to be submitted for peer-review by fall 2020. The third manuscript (chapter 4) summarizes an analysis of CHILD study data that assesses the association of dietary patterns with infant wheeze and asthma through age 3. In chapter 5, the thesis concludes by summarizing study limitations, epidemiological implications, clinical relevance of these findings and future directions. Appendices are also included to highlight research methodology and describe comprehensively all data analyses. / Thesis / Master of Science (MSc) / This paper-based thesis includes my graduate research work to satisfy the requirements for a masters in science (M.Sc.) degree in the Medical Sciences department. The focus of this thesis is to contribute an important study of the role of maternal and infant nutrition in the development of asthma and wheeze in children. My research findings are presented as original manuscripts of a systematic review protocol, systematic review, and a primary analysis of data collected as part of the CHILD longitudinal birth cohort study. At present, the first 2 manuscripts are under review by scientific journals; and the third will be submitted for peer-review in October 2021.