title: Undernutrition and malaria in pregnancy - a dangerous dyad?
abstract: 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.
  
  
  
  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.
  
  
  
  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.
authors.affiliation: Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Victoria, Australia.|Simpson Centre for Reproductive Health, Edinburgh Royal Infirmary, Edinburgh, UK.
authors.forename: Holger W
authors.initials: HW
authors.lastname: Unger
authors.affiliation: Department of Paediatrics, University of Tampere School of Medicine, Tampere, Finland.|Department for International Health, University of Tampere School of Medicine, Tampere, Finland.|Department of Paediatrics, Tampere University Hospital, Tampere, Finland.
authors.forename: Per
authors.initials: P
authors.lastname: Ashorn
authors.affiliation: Department of Epidemiology, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Jordan E
authors.initials: JE
authors.lastname: Cates
authors.affiliation: Program in International and Community Nutrition and Department of Nutrition, University of California, Davis, CA, USA.
authors.forename: Kathryn G
authors.initials: KG
authors.lastname: Dewey
authors.affiliation: Department of Medicine at the Doherty Institute, The University of Melbourne, Melbourne, Victoria, Australia. sroger@unimelb.edu.au.
authors.forename: Stephen J
authors.initials: SJ
authors.lastname: Rogerson
mesh_terms: D005260:Female; D047109:Fetal Development; D005317:Fetal Growth Retardation / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control; D006801:Humans; D007231:Infant, Newborn; D008288:Malaria / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control; D044342:Malnutrition / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control; D010920:Placenta / Q000469:parasitology; D011247:Pregnancy; D015597:Pregnancy Complications, Parasitic / Q000175:diagnosis / Q000453:epidemiology* / Q000517:prevention & control; D011256:Pregnancy Outcome; D047928:Premature Birth / Q000175:diagnosis / Q000453:epidemiology / Q000517:prevention & control; D050497:Stillbirth / Q000453:epidemiology
keywords: Fetal growth restriction; Low birthweight; Malaria; Nutrition; Pregnancy