Vitamins and minerals, education, and self-care need during preconception to 1000 days of life in Southeast Asia: An expert panel opinion

**Background:** The Developmental Origins of Health and Disease hypothesis underscores that maternal nutrition during the critical 'first 1000 days' (from conception to age 2) has lifelong health consequences. Despite economic development in Southeast Asia, inadequate maternal micronutrient intake remains a major contributor to poor maternal and fetal health. This expert opinion article summarizes evidence-based opinions on the importance of micronutrient supplementation, education, and self-care for women in Southeast Asia during preconception, pregnancy, and lactation, with additional insights from the COVID-19 pandemic.

**Methods:** Nine experts from Southeast Asia (Philippines, Malaysia, Thailand) representing obstetrics and gynecology (7), dietetics (1), and epidemiology (1) convened virtually on July 13, 2021. A systematic literature search was conducted using PubMed, MEDLINE, Embase, and Scopus. A pre-meeting survey provided insights on current practices and challenges. The expert panel discussed published evidence and clinical experiences to identify nutritional gaps. Recommendations were graded from A to C based on evidence level, or as a good practice point (GPP), adapted from the National Collaborating Centre for Mental Health.

**Key Results:** The panel identified several critical findings: - **Prevalence of Malnutrition:** Biswas et al. reported a pooled prevalence of 20% for both underweight and overweight in Southeast Asian women. In the Philippines, 14% of women of reproductive age were underweight, while 27% were overweight or obese. A Vietnamese study found 32.7% of women were underweight before pregnancy. The risk of childhood wasting was 69% higher for children of mothers with low BMI (<18.5 kg/m²). - **Micronutrient Gaps:** Inadequate intake of vitamin B12 was found in seven Asian regions. In Myanmar, 86% of pregnant women had low to moderate knowledge of nutritional needs. In Malaysia, 87.9% were aware of dietary supplements, but only 49.1% took them. A study from Thailand reported low dietary folate intake in 65.5% and low serum folate in 18% of women of childbearing age. - **Supplementation Benefits:** Multiple-micronutrient (MMN) supplementation showed improvement in preterm birth, small for gestational age (SGA), and low birth weight (LBW). A greater risk reduction of LBW and SGA was observed with MMN compared to iron-folate supplements. An RCT from Vietnam reported that preconception iron-folic acid (IFA) supplementation significantly improved linear growth and fine motor development (0.41; 95% CI: 0.05, 0.77) at 2 years of age. Iron supplementation increased hemoglobin concentration among Vietnamese women by 0.4 g/dL in the second trimester (p=0.017) and 0.7 g/dL in the third trimester (p<0.001). Weekly IFA supplements containing 2.8 mg folic acid were seven times more likely (RR 7.3; 95% CI: 3.9, 13.7; p<0.0001) to achieve RBC folate >748 nmol/L, a level associated with low NTD risk. - **COVID-19 Impact:** A systematic review found a significant decrease in antenatal care visits (p<0.0001) and an increase in remote care (p<0.0001) during the pandemic. The panel noted that inadequate nutritional and self-care information became a greater challenge. - **Education and Self-Care:** Higher education positively impacts maternal and child nutrition. In Thailand, children of mothers with no formal education were more likely to be underweight, stunted, or wasted (71%, 61%, and 48%, respectively) compared to children of mothers with education beyond secondary school (12%). Family-based educational programs and the use of telemedicine and mHealth applications were recommended.

**Clinical Implications:** The expert panel emphasizes that nutritional interventions should start before conception and continue through lactation. Key recommendations include: (1) promoting awareness of healthy dietary choices; (2) ensuring adequate intake of iron, folic acid, calcium, iodine, vitamin B12, and vitamin D; (3) considering MMN supplementation over IFA alone in settings where multiple deficiencies are common; (4) implementing family-based education programs; (5) leveraging digital tools for self-care and remote consultations, especially in pandemic contexts; and (6) involving policymakers and multisectoral stakeholders to address barriers to dietary changes. The panel graded several opinions as Level A evidence, including that women's nutritional status before and during pregnancy impacts fetal growth, and that multiple nutrients are important from preconception through the first 1000 days.