251
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Khara T, Mwangome M, Ngari M, Dolan C. Children concurrently wasted and stunted: A meta-analysis of prevalence data of children 6-59 months from 84 countries. MATERNAL & CHILD NUTRITION 2018; 14:e12516. [PMID: 28944990 PMCID: PMC5901398 DOI: 10.1111/mcn.12516] [Citation(s) in RCA: 87] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 07/27/2017] [Accepted: 08/25/2017] [Indexed: 12/02/2022]
Abstract
Children can be stunted and wasted at the same time. Having both deficits greatly elevates risk of mortality. The analysis aimed to estimate the prevalence and burden of children aged 6-59 months concurrently wasted and stunted. Data from demographic and health survey and Multi-indicator Cluster Surveys datasets from 84 countries were analysed. Overall prevalence for being wasted, stunted, and concurrently wasted and stunted among children 6 to 59 months was calculated. A pooled prevalence of concurrence was estimated and reported by gender, age, United Nations regions, and contextual categories. Burden was calculated using population figures from the global joint estimates database. The pooled prevalence of concurrence in the 84 countries was 3.0%, 95% CI [2.97, 3.06], ranging from 0% to 8.0%. Nine countries reported a concurrence prevalence greater than 5%. The estimated burden was 5,963,940 children. Prevalence of concurrence was highest in the 12- to 24-month age group 4.2%, 95% CI [4.1, 4.3], and was significantly higher among boys 3.54%, 95% CI [3.47, 3.61], compared to girls; 2.46%, 95% CI [2.41, 2.52]. Fragile and conflict-affected states reported significantly higher concurrence 3.6%, 95% CI [3.5, 3.6], than those defined as stable 2.24%, 95% CI [2.18, 2.30]. This analysis represents the first multiple country estimation of the prevalence and burden of children concurrently wasted and stunted. Given the high risk of mortality associated with concurrence, the findings indicate a need to report on this condition as well as investigate whether these children are being reached through existing programmes.
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Affiliation(s)
| | - Martha Mwangome
- KEMRI‐Wellcome Trust Research ProgrammeKEMRI Centre for Geographic Medicine Research‐CoastKilifiKenya
| | - Moses Ngari
- KEMRI‐Wellcome Trust Research ProgrammeKEMRI Centre for Geographic Medicine Research‐CoastKilifiKenya
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252
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Cheng Z, Shi L, Li Y, Wang Y, Zhang J. Using structural equation modelling to assess factors influencing children's growth and nutrition in rural China. Public Health Nutr 2018; 21:1167-1175. [PMID: 29224576 PMCID: PMC10261315 DOI: 10.1017/s1368980017003494] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 10/01/2017] [Accepted: 10/27/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Children's poor growth and nutrition status has serious consequences and therefore it is important to understand its contributing factors. DESIGN A community-based interventional study focusing on child feeding was conducted in a rural community in China. Data from the intervention group at baseline (1-4 months of age) and follow-up visits (12 and 18 months of age) were used in the present study (n 236). A structural equation model was generated to explore the effects of family wealth, household food safety, dietary intake, diseases and other factors on the growth and nutrition of young children. RESULTS Mother's knowledge and behaviours on household food safety had positive effects on children's weight-for-age Z-score (WAZ; β direct=0·03 and 0·15, respectively, at 12 months of age; β direct=0·02 and 0·08, respectively, at 18 months; P<0·05) and weight-for-length Z-score (WLZ; β direct=0·04 and 0·21, respectively, at 12 months of age; β direct=0·01 and 0·06, respectively, at 18 months; P<0·05). While mothers' feeding behaviours and children's dietary intake at 12 months of age were positively associated with WAZ and/or WLZ at current and later ages, children's diseases were negatively associated with WAZ and WLZ cross-sectionally. CONCLUSIONS Caregiver's knowledge and feeding behaviours, and children's dietary intake and diseases, are factors influencing the WAZ and WLZ of children. Promoting feeding and health knowledge and behaviours at early stages of childhood can improve children's physical growth at later ages.
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Affiliation(s)
- Zixi Cheng
- Department of Child, Adolescent and Women’s Health, School of Public Health, Peking University, Beijing 100191, People’s Republic of China
- Institute of Reproductive and Child Health, Peking University/Key Laboratory of Reproductive Health, National Health and Family Planning Commission of the People’s Republic of China, Beijing 100191, People’s Republic of China
| | - Ling Shi
- College of Nursing and Health Sciences, University of Massachusetts Boston, Boston, MA, USA
| | - Ying Li
- Department of Child, Adolescent and Women’s Health, School of Public Health, Peking University, Beijing 100191, People’s Republic of China
| | - Yan Wang
- Department of Child, Adolescent and Women’s Health, School of Public Health, Peking University, Beijing 100191, People’s Republic of China
| | - Jingxu Zhang
- Department of Child, Adolescent and Women’s Health, School of Public Health, Peking University, Beijing 100191, People’s Republic of China
- Institute of Reproductive and Child Health, Peking University/Key Laboratory of Reproductive Health, National Health and Family Planning Commission of the People’s Republic of China, Beijing 100191, People’s Republic of China
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253
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Huang M, Sudfeld C, Ismail A, Vuai S, Ntwenya J, Mwanyika-Sando M, Fawzi W. Maternal Dietary Diversity and Growth of Children Under 24 Months of Age in Rural Dodoma, Tanzania. Food Nutr Bull 2018; 39:219-230. [DOI: 10.1177/0379572118761682] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To identify predictors of maternal dietary diversity in rural Dodoma, Tanzania and assess its association with child growth outcomes. Methods: A cross-sectional survey of 361 mothers with children under 24 months of age was conducted in 5 villages in rural Dodoma, Tanzania. Maternal diets were assessed using food frequency questionnaires, and dietary diversity was categorized using Minimum Dietary Diversity for Women (MDD-W) guidelines. Child anthropometric measures were taken to calculate height-for-age z-score (HAZ), weight-for-height z-score (WHZ), and weight-for-age z-score (WAZ). Linear and logistic regressions were used to examine the association between maternal dietary diversity and children’s growth outcomes. Results: About 40% of mothers did not consume a diverse diet (MDD-W < 5), and 35% of children were stunted. Household production of greater number of crops was associated with greater MDD-W scores ( P < .01). Greater maternal dietary diversity was associated with significantly greater child WHZ (mean difference = 0.44; 95% confidence interval [CI]: 0.10-0.78; P = .01), WAZ (mean difference = 0.37; 95% CI: 0.08-0.65; P = .01), and reduced risk of wasting (odds ratio = 0.22; 95% CI: 0.07-0.66; P = .01). Conclusions: Greater maternal dietary diversity was associated with improved child WHZ and WAZ outcomes. Sustainable interventions to increase maternal dietary diversity may improve WHZ and WAZ in young children in similar settings.
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Affiliation(s)
- Megan Huang
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Christopher Sudfeld
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | | | - Said Vuai
- University of Dodoma, Dodoma, Tanzania
| | | | | | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- University of Dodoma, Dodoma, Tanzania
- Africa Academy for Public Health, Dar es Salaam, Tanzania
- Department of Epidemiology and Nutrition, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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254
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Pearson R, Killedar M, Petravic J, Kakietek JJ, Scott N, Grantham KL, Stuart RM, Kedziora DJ, Kerr CC, Skordis-Worrall J, Shekar M, Wilson DP. Optima Nutrition: an allocative efficiency tool to reduce childhood stunting by better targeting of nutrition-related interventions. BMC Public Health 2018; 18:384. [PMID: 29558915 PMCID: PMC5861618 DOI: 10.1186/s12889-018-5294-z] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Accepted: 03/12/2018] [Indexed: 11/11/2022] Open
Abstract
Background Child stunting due to chronic malnutrition is a major problem in low- and middle-income countries due, in part, to inadequate nutrition-related practices and insufficient access to services. Limited budgets for nutritional interventions mean that available resources must be targeted in the most cost-effective manner to have the greatest impact. Quantitative tools can help guide budget allocation decisions. Methods The Optima approach is an established framework to conduct resource allocation optimization analyses. We applied this approach to develop a new tool, ‘Optima Nutrition’, for conducting allocative efficiency analyses that address childhood stunting. At the core of the Optima approach is an epidemiological model for assessing the burden of disease; we use an adapted version of the Lives Saved Tool (LiST). Six nutritional interventions have been included in the first release of the tool: antenatal micronutrient supplementation, balanced energy-protein supplementation, exclusive breastfeeding promotion, promotion of improved infant and young child feeding (IYCF) practices, public provision of complementary foods, and vitamin A supplementation. To demonstrate the use of this tool, we applied it to evaluate the optimal allocation of resources in 7 districts in Bangladesh, using both publicly available data (such as through DHS) and data from a complementary costing study. Results Optima Nutrition can be used to estimate how to target resources to improve nutrition outcomes. Specifically, for the Bangladesh example, despite only limited nutrition-related funding available (an estimated $0.75 per person in need per year), even without any extra resources, better targeting of investments in nutrition programming could increase the cumulative number of children living without stunting by 1.3 million (an extra 5%) by 2030 compared to the current resource allocation. To minimize stunting, priority interventions should include promotion of improved IYCF practices as well as vitamin A supplementation. Once these programs are adequately funded, the public provision of complementary foods should be funded as the next priority. Programmatic efforts should give greatest emphasis to the regions of Dhaka and Chittagong, which have the greatest number of stunted children. Conclusions A resource optimization tool can provide important guidance for targeting nutrition investments to achieve greater impact.
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Affiliation(s)
- Ruth Pearson
- Burnet Institute, Melbourne, Australia. .,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia. .,Optima Consortium for Decision Science, Melbourne, Australia.
| | - Madhura Killedar
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Optima Consortium for Decision Science, Melbourne, Australia
| | - Janka Petravic
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Optima Consortium for Decision Science, Melbourne, Australia
| | | | - Nick Scott
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Optima Consortium for Decision Science, Melbourne, Australia
| | - Kelsey L Grantham
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Optima Consortium for Decision Science, Melbourne, Australia
| | - Robyn M Stuart
- Burnet Institute, Melbourne, Australia.,Optima Consortium for Decision Science, Melbourne, Australia.,Department of Mathematical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - David J Kedziora
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Optima Consortium for Decision Science, Melbourne, Australia
| | - Cliff C Kerr
- Burnet Institute, Melbourne, Australia.,Optima Consortium for Decision Science, Melbourne, Australia.,Complex Systems Group, School of Physics, University of Sydney, Sydney, Australia
| | - Jolene Skordis-Worrall
- Optima Consortium for Decision Science, Melbourne, Australia.,Institute for Global Health, University College London, London, UK
| | - Meera Shekar
- The World Bank, ICF International, Washington D.C., USA
| | - David P Wilson
- Burnet Institute, Melbourne, Australia.,Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Optima Consortium for Decision Science, Melbourne, Australia
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255
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Farràs M, Chandwe K, Mayneris-Perxachs J, Amadi B, Louis-Auguste J, Besa E, Zyambo K, Guerrant R, Kelly P, Swann JR. Characterizing the metabolic phenotype of intestinal villus blunting in Zambian children with severe acute malnutrition and persistent diarrhea. PLoS One 2018; 13:e0192092. [PMID: 29499047 PMCID: PMC5834158 DOI: 10.1371/journal.pone.0192092] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 01/16/2018] [Indexed: 02/07/2023] Open
Abstract
Background Environmental enteric dysfunction (EED) is widespread throughout the tropics and in children is associated with stunting and other adverse health outcomes. One of the hallmarks of EED is villus damage. In children with severe acute malnutrition (SAM) the severity of enteropathy is greater and short term mortality is high, but the metabolic consequences of enteropathy are unknown. Here, we characterize the urinary metabolic alterations associated with villus health, classic enteropathy biomarkers and anthropometric measurements in severely malnourished children in Zambia. Methods/Principal findings We analysed 20 hospitalised children with acute malnutrition aged 6 to 23 months in Zambia. Small intestinal biopsies were assessed histologically (n = 15), anthropometric and gut function measurements were collected and the metabolic phenotypes were characterized by 1H nuclear magnetic resonance (NMR) spectroscopy. Endoscopy could not be performed on community controls children. Growth parameters were inversely correlated with enteropathy biomarkers (p = 0.011) and parameters of villus health were inversely correlated with translocation and permeability biomarkers (p = 0.000 and p = 0.015). Shorter villus height was associated with reduced abundance of metabolites related to gut microbial metabolism, energy and muscle metabolism (p = 0.034). Villus blunting was also related to increased sucrose excretion (p = 0.013). Conclusions/Significance Intestinal villus blunting is associated with several metabolic perturbations in hospitalized children with severe undernutrition. Such alterations include altered muscle metabolism, reinforcing the link between EED and growth faltering, and a disruption in the biochemical exchange between the gut microbiota and host. These findings extend our understanding on the downstream consequences of villus blunting and provide novel non-invasive biomarkers of enteropathy dysfunction. The major limitations of this study are the lack of comparative control group and gut microbiota characterization.
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Affiliation(s)
- Marta Farràs
- Computational and Systems Medicine Group, Division of Surgery and Cancer, Imperial College, London, United Kingdom
- CIBER de Fisiopatología de la Obesidad y la Nutrición (CIBEROBN), Barcelona, Spain
- * E-mail: (JRS); (MF)
| | - Kanta Chandwe
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Jordi Mayneris-Perxachs
- Computational and Systems Medicine Group, Division of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Beatrice Amadi
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - John Louis-Auguste
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Ellen Besa
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
| | - Richard Guerrant
- University of Virginia, Charlottesville, VA, United States of America
| | - Paul Kelly
- Tropical Gastroenterology & Nutrition group, University of Zambia School of Medicine, Lusaka, Zambia
- Barts & The London School of Medicine, Queen Mary University of London, London, United Kingdom
| | - Jonathan Richard Swann
- Computational and Systems Medicine Group, Division of Surgery and Cancer, Imperial College, London, United Kingdom
- * E-mail: (JRS); (MF)
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256
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Perumal N, Bassani DG, Roth DE. Use and Misuse of Stunting as a Measure of Child Health. J Nutr 2018; 148:311-315. [PMID: 29546307 DOI: 10.1093/jn/nxx064] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/04/2017] [Indexed: 11/14/2022] Open
Abstract
The term "stunting" has become pervasive in international nutrition and child health research, program, and policy circles. Although originally intended as a population-level statistical indicator of children's social and economic deprivation, the conventional anthropometric definition of stunting (height-for-age z scores <-2 SD) is now widely used to define chronic malnutrition. Epidemiologists often portray it as a disease, making inferences about the causes of growth faltering based on comparisons between stunted (i.e., undernourished) and nonstunted children. Stunting is commonly used to monitor public health and nutrition program effectiveness alongside calls for the "elimination of stunting." However, there is no biological basis for the -2 SD cutoff to define stunting, making it a poor individual-level classifier of malnutrition or disease. In fact, in many low- and middle-income countries, children above and below the threshold are similarly affected by growth-limiting exposures. We argue that the common use of stunting as an indicator of child linear growth has contributed to unsubstantiated assumptions about the biological mechanisms underlying linear growth impairment in low- and middle-income countries and has led to a systematic underestimation of the burden of linear growth deficits among children in low-resource settings. Moreover, because nutrition-specific short-term public health interventions may result in relatively minor changes in child height, the use of stunting prevalence to monitor health or nutrition program effectiveness may be inappropriate. A more nuanced approach to the application and interpretation of stunting as an indicator in child growth research and public health programming is warranted.
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Affiliation(s)
- Nandita Perumal
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global Child Health, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, ON, Canada
| | - Diego G Bassani
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Centre for Global Child Health, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
| | - Daniel E Roth
- Centre for Global Child Health, Peter Gilgan Centre for Research and Learning, Hospital for Sick Children, Toronto, ON, Canada.,Department of Paediatrics, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
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257
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Lassi ZS, Irfan O, Hadi R, Das JK, Bhutta ZA. PROTOCOL: Effects of interventions for infant and young child feeding (IYCF) promotion on optimal IYCF practices, nutrition, growth and health in low- and middle-income countries: a systematic review. CAMPBELL SYSTEMATIC REVIEWS 2018; 14:1-26. [PMID: 37131389 PMCID: PMC8427994 DOI: 10.1002/cl2.189] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
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258
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Relationship between growth and illness, enteropathogens and dietary intakes in the first 2 years of life: findings from the MAL-ED birth cohort study. BMJ Glob Health 2017; 2:e000370. [PMID: 29333282 PMCID: PMC5759708 DOI: 10.1136/bmjgh-2017-000370] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 09/04/2017] [Accepted: 09/17/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Dietary and illness factors affect risk of growth faltering; the role of enteropathogens is less clear. As part of the Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development (MAL-ED) study, we quantify the effects of enteropathogen infection, diarrhoea and diet on child growth. METHODS Newborns were enrolled and followed until 24 months. Length and weight were assessed monthly. Illnesses and breastfeeding practices were documented biweekly; from 9 to 24 months, non-breast milk intakes were quantified monthly. Routinely collected non-diarrhoeal stools were analysed for a broad array of enteropathogens. A linear piecewise spline model was used to quantify associations of each factor with growth velocity in seven of eight MAL-ED sites; cumulative effects on attained size at 24 months were estimated for mean, low (10th percentile) and high (90th percentile) exposure levels. Additionally, the six most prevalent enteropathogens were evaluated for their effects on growth. RESULTS Diarrhoea did not have a statistically significant effect on growth. Children with high enteropathogen exposure were estimated to be 1.21±0.33 cm (p<0.001; 0.39 length for age (LAZ)) shorter and 0.08±0.15 kg (p=0.60; 0.08 weight-for-age (WAZ)) lighter at 24 months, on average, than children with low exposure. Campylobacter and enteroaggregativeEscherichia coli detections were associated with deficits of 0.83±0.33 and 0.85±0.31 cm in length (p=0.011 and 0.001) and 0.22±0.15 and 0.09±0.14 kg in weight (p=0.14 and 0.52), respectively. Children with low energy intakes and protein density were estimated to be 1.39±0.33 cm (p<0.001; 0.42 LAZ) shorter and 0.81±0.15 kg (p<0.001; 0.65 WAZ) lighter at 24 months than those with high intakes. CONCLUSIONS Reducing enteropathogen burden and improving energy and protein density of complementary foods could reduce stunting.
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259
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Adamu W, Jara D, Alemayehu M, Burrowes S. Risk factors associated with poor health outcomes for children under the age of 5 with moderate acute malnutrition in rural fagita lekoma district, Awi Zone, Amhara, Ethiopia, 2016. BMC Nutr 2017; 3:88. [PMID: 32153864 PMCID: PMC7050731 DOI: 10.1186/s40795-017-0208-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 12/13/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Left untreated, moderate acute malnutrition (MAM) in children can lead to severe acute malnutrition, stunting, developmental delays, and death. Despite recent progress the prevalence of malnutrition remains high throughout Ethiopia. The ability to make accurate prognoses and develop effective treatment strategies for children with MAM is currently limited and, as result, a significant proportion of children with MAM fail to recover even with treatment. We seek to address this limitation by assessing the risk factors for poor outcomes among children under the age of 5 with MAM in a rural area of Ethiopia's Amhara Region. This region is considered relatively food secure and does not have food supplementation treatment programs. METHODS We conducted a prospective cohort study of 404 randomly sampled children, 0-59 months old stratified by household food security status. We followed the study children for approximately 2 months, assessing their health status; and used bivariate and multivariate Cox-proportional hazard regression models to identify risk factors for poor health outcomes. RESULTS Household food security was significantly associated with low recovery from MAM: 191 (60%) of children in food-insecure and 129 (40%) of children in food-secure households had poor health outcomes. The risk factors found to be significantly associated with poor health outcomes included the duration of exclusive breastfeeding (AHR 1.50, 95%CI: 1.05, 2.15), dietary diversity (AHR 1.74, 95%CI: 1.18, 2.54), and maternal mid-upper arm circumference (AHR=1.36, 95% CI: 1.04, 1.86). Children from pregnancies that were wanted but unplanned had 80% higher incidence of poor health outcomes than others, and children from pregnancies that were both unwanted and unplanned had more than double the incidence of poor health outcomes compared to their counterparts. CONCLUSION We found that without treatment, the majority of children from food insecure households and over a third of children from food secure households did not recover from MAM. Maternal factors particularly the mother's ability to plan her pregnancy were the main determinants of recovery in this study. Together these findings support arguments for targeting of nutrition support programs to vulnerable households regardless of regional food security status, and for closely integrating robust family planning, and antenatal care services with nutrition interventions.
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Affiliation(s)
| | - Dube Jara
- Department of Public Health, College of Medicine and Health Science Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Mulunesh Alemayehu
- Department of Public Health, College of Medicine and Health Science Debre Markos University, P.O. Box 269, Debre Markos, Ethiopia
| | - Sahai Burrowes
- Public Health Program, College of Education and Health Sciences, Touro University California, 1310 Club Drive, Mare Island Vallejo, CA 94592 USA
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260
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Semba RD, Trehan I, Li X, Salem N, Moaddel R, Ordiz MI, Maleta KM, Kraemer K, Manary MJ. Low serum ω-3 and ω-6 polyunsaturated fatty acids and other metabolites are associated with poor linear growth in young children from rural Malawi. Am J Clin Nutr 2017; 106:1490-1499. [PMID: 29070563 PMCID: PMC5698844 DOI: 10.3945/ajcn.117.164384] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 10/03/2017] [Indexed: 11/14/2022] Open
Abstract
Background: Stunting affects ∼25% of children <5 y of age and is associated with impaired cognitive and motor development and increased morbidity and mortality. The pathogenesis of stunting is poorly understood.Objective: The purpose of this study was to identify altered metabolic pathways associated with child stunting.Design: We measured 677 serum metabolites using liquid chromatography-tandem mass spectrometry in a cross-sectional study of 400 Malawian children aged 12-59 mo, of whom 62% were stunted.Results: A low height-for-age z score (HAZ) was associated with lower serum concentrations of 1) ω-3 (n-3) and ω-6 (n-6) polyunsaturated fatty acids (PUFAs), 2) sulfated neurosteroids, which play a role in brain development, 3) carnitine, a conditionally essential nutrient with an important role in the carnitine shuttle for the metabolism of fatty acids and energy production, and 4) γ-glutamyl amino acids, which represent an altered γ-glutamyl cycle of glutathione metabolism. A low HAZ was associated with significantly higher serum concentrations of 5 biomarkers related to cigarette smoke exposure.Conclusions: This metabolomics study shows a cross-sectional association between stunting and low serum ω-3 and ω-6 long-chain PUFAs, which are essential for growth and development; low sulfated neurosteroids, which play a role in brain development; low carnitine, which is essential for β-oxidation of fatty acids; alterations in glutathione metabolism; and increased serum metabolites that are associated with secondhand tobacco smoke exposure. This trial was registered at www.controlled-trials.com as ISRCTN14597012.
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Affiliation(s)
- Richard D Semba
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD;
| | - Indi Trehan
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO
| | - Ximin Li
- Departments of Biostatistics and
| | | | | | - M Isabel Ordiz
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO
| | - Kenneth M Maleta
- College of Medicine, University of Malawi, Blantyre, Malawi; and
| | - Klaus Kraemer
- International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD;,Sight and Life, Basel, Switzerland
| | - Mark J Manary
- Department of Pediatrics, Washington University at St. Louis, St. Louis, MO
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261
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Balhara KS, Silvestri DM, Tyler Winders W, Selvam A, Kivlehan SM, Becker TK, Levine AC. Impact of nutrition interventions on pediatric mortality and nutrition outcomes in humanitarian emergencies: A systematic review. Trop Med Int Health 2017; 22:1464-1492. [PMID: 28992388 DOI: 10.1111/tmi.12986] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Malnutrition contributes to paediatric morbidity and mortality in disasters and complex emergencies, but summary data describing specific nutritional interventions in these settings are lacking. This systematic review aimed to characterise such interventions and their effects on paediatric mortality, anthropometric measures and serum markers of nutrition. METHODS A systematic search of OVID MEDLINE, Cochrane Library and relevant grey literature was conducted. We included all randomised controlled trials and observational controlled studies evaluating effectiveness of nutritional intervention(s) on defined health outcomes in children and adolescents (0-18 years) within a disaster or complex emergency. We extracted study characteristics, interventions and outcomes data. Study quality was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria. RESULTS A total of 31 studies met inclusion criteria. Most were conducted in Africa (17), during periods of conflict or hunger gaps (14), and evaluated micronutrient supplementation (14) or selective feeding (10). Overall study quality was low, with only two high and four moderate quality studies. High- and medium-quality studies demonstrated positive impact of fortified spreads, ready-to-use therapeutic foods, micronutrient supplementation, and food and cash transfers. CONCLUSION In disasters and complex emergencies, high variability and low quality of controlled studies on paediatric malnutrition limit meaningful data aggregation. If existing research gaps are to be addressed, the inherent unpredictability of humanitarian emergencies and ethical considerations regarding controls may warrant a paradigm shift in what constitutes adequate methods. Periodic hunger gaps may offer a generalisable opportunity for robust trials, but consensus on meaningful nutritional endpoints is needed.
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Affiliation(s)
- Kamna S Balhara
- Department of Emergency Medicine, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - David M Silvestri
- Department of Emergency Medicine, Harvard Affiliated Emergency Medicine Residency, Brigham and Women's Hospital, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - W Tyler Winders
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Anand Selvam
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Sean M Kivlehan
- Department of Emergency Medicine, Harvard Medical School, Division of International Emergency Medicine and Humanitarian Programs, Brigham and Women's Hospital, Boston, MA, USA
| | - Torben K Becker
- Department of Emergency Medicine, University of Florida, Gainesville, FL, USA
| | - Adam C Levine
- Department of Emergency Medicine, Warren Alpert Medical School of Brown University, Providence, RI, USA
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Skrable K, Bilal S, Sharma R, Robertson S, Ashenafi Y, Nasrin S, Alam NH, Levine AC. The Effects of Malnutrition and Diarrhea Type on the Accuracy of Clinical Signs of Dehydration in Children under Five: A Prospective Cohort Study in Bangladesh. Am J Trop Med Hyg 2017; 97:1345-1354. [PMID: 29140238 DOI: 10.4269/ajtmh.17-0277] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Affiliation(s)
- Kelly Skrable
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Saadiyah Bilal
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Rashmi Sharma
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sarah Robertson
- Brown University School of Public Health, Providence, Rhode Island
| | | | - Sabiha Nasrin
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Nur H Alam
- International Centre for Diarrhoeal Disease Research, Dhaka, Bangladesh
| | - Adam C Levine
- Warren Alpert Medical School of Brown University, Providence, Rhode Island
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263
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Kolesar RJ, Audibert M. Postneonatal mortality impacts following grants from the Gavi Vaccine Alliance: an econometric analysis from 2000 to 2014. Public Health 2017; 153:163-171. [PMID: 29102832 DOI: 10.1016/j.puhe.2017.08.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 07/08/2017] [Accepted: 08/28/2017] [Indexed: 10/18/2022]
Abstract
We completed a retrospective multivariate panel study to evaluate the effect of Gavi Vaccine Alliance grants on vaccine-preventable disease (VPD) postneonatal mortality. We separately tested a composite VPD mortality rate and five vaccine-preventable mortality rates: pertussis, meningitis, measles, diarrhea, and pneumonia (lower-respiratory infection) as dependent variables. All 77 countries eligible for Gavi assistance from 2000 to 2014 were included in the study. To isolate the effect of Gavi funding in our primary model, we controlled for known and likely predictors of child mortality. We found evidence that, among other factors, Gavi investment, antenatal care access, and girls' primary education are important elements to reduce vaccine-preventable mortality rates. For every $1 per capita invested by the Gavi Vaccine Alliance, there are statistically significant effects decreasing the VPD postneonatal mortality rate by 1.848 per 1000 live births. We also found Gavi investments to be significantly associated with reductions in three VPD-specific rates: pertussis, meningitis, and pneumonia. We conclude that Gavi investments in developing country immunization programs have measurably contributed to reductions in postneonatal VPD mortality rates.
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Affiliation(s)
- R J Kolesar
- Centre D'Etudes et de Recherches sur le Développement International (CERDI-CNRS), Université Clermont-Auvergne, 65 Boulevard F. Mitterrand, 63000 Clermont-Ferrand, France.
| | - M Audibert
- Centre D'Etudes et de Recherches sur le Développement International (CERDI-CNRS), Université Clermont-Auvergne, 65 Boulevard F. Mitterrand, 63000 Clermont-Ferrand, France.
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Abstract
The global impact of childhood malnutrition is staggering. The synergism between malnutrition and infection contributes substantially to childhood morbidity and mortality. Anthropometric indicators of malnutrition are associated with the increased risk and severity of infections caused by many pathogens, including viruses, bacteria, protozoa, and helminths. Since childhood malnutrition commonly involves the inadequate intake of protein and calories, with superimposed micronutrient deficiencies, the causal factors involved in impaired host defense are usually not defined. This review focuses on literature related to impaired host defense and the risk of infection in primary childhood malnutrition. Particular attention is given to longitudinal and prospective cohort human studies and studies of experimental animal models that address causal, mechanistic relationships between malnutrition and host defense. Protein and micronutrient deficiencies impact the hematopoietic and lymphoid organs and compromise both innate and adaptive immune functions. Malnutrition-related changes in intestinal microbiota contribute to growth faltering and dysregulated inflammation and immune function. Although substantial progress has been made in understanding the malnutrition-infection synergism, critical gaps in our understanding remain. We highlight the need for mechanistic studies that can lead to targeted interventions to improve host defense and reduce the morbidity and mortality of infectious diseases in this vulnerable population.
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265
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Clermont A, Walker N. Nutrition Interventions in the Lives Saved Tool (LiST). J Nutr 2017; 147:2132S-2140S. [PMID: 28904118 DOI: 10.3945/jn.116.243766] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 01/12/2016] [Accepted: 03/01/2017] [Indexed: 11/14/2022] Open
Abstract
The Lives Saved Tool (LiST) was initially developed in 2003 to estimate the impact of increasing coverage of efficacious interventions on under-5 mortality. Over time, the model has been expanded to include more outcomes (neonatal mortality, maternal mortality, stillbirths) and interventions. The model has also added risk factors, such as stunting and wasting, and over time has attempted to capture a full range of nutrition and nutrition-related interventions (e.g., antenatal supplementation, breastfeeding promotion, child supplemental feeding, acute malnutrition treatment), practices (e.g., age-appropriate breastfeeding), and outcomes (e.g., stunting, wasting, birth outcomes, maternal anemia). This article reviews the overall nutrition-related structure, assumptions, and outputs that are currently available in LiST. This review focuses on the new assumptions and structure that have been added to the model as part of the current effort to expand and improve the nutrition modeling capability of LiST. It presents the full set of linkages in the model that relate to nutrition outcomes, as well as the research literature used to support those linkages.
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Affiliation(s)
- Adrienne Clermont
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Neff Walker
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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Rainfall shocks are not necessarily a sensitive early indicator of changes in wasting prevalence. Eur J Clin Nutr 2017; 72:177-178. [PMID: 28901334 PMCID: PMC5765168 DOI: 10.1038/ejcn.2017.144] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/24/2017] [Accepted: 08/01/2017] [Indexed: 11/08/2022]
Abstract
Evidence on the impact of weather shocks on child nutrition focuses on linear growth retardation (stunting) and thus, associates the effect of a short-term measure (weather events) on a cumulative measure (attained height). Relatively little is known on how weather shocks predict increases in wasting in a population. This study explores whether deviation in rainfall in Ethiopia, a drought prone country, is a sensitive indicator of future increases in wasting. Around 12% of children 0–23 months were wasted, but we found no consistent association between the rainfall shock variables and child weight-for-height Z-scores. The results indicate that monitoring rainfall does not provide a practical early warning to use for scaling up financing and management of preventative measures without additional information to increase precision.
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268
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Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory tract infections in 195 countries: a systematic analysis for the Global Burden of Disease Study 2015. THE LANCET. INFECTIOUS DISEASES 2017; 17:1133-1161. [PMID: 28843578 PMCID: PMC5666185 DOI: 10.1016/s1473-3099(17)30396-1] [Citation(s) in RCA: 476] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Revised: 06/14/2017] [Accepted: 06/15/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND The Global Burden of Diseases, Injuries, and Risk Factors (GBD) Study 2015 provides an up-to-date analysis of the burden of lower respiratory tract infections (LRIs) in 195 countries. This study assesses cases, deaths, and aetiologies spanning the past 25 years and shows how the burden of LRI has changed in people of all ages. METHODS We estimated LRI mortality by age, sex, geography, and year using a modelling platform shared across most causes of death in the GBD 2015 study called the Cause of Death Ensemble model. We modelled LRI morbidity, including incidence and prevalence, using a meta-regression platform called DisMod-MR. We estimated aetiologies for LRI using two different counterfactual approaches, the first for viral pathogens, which incorporates the aetiology-specific risk of LRI and the prevalence of the aetiology in LRI episodes, and the second for bacterial pathogens, which uses a vaccine-probe approach. We used the Socio-demographic Index, which is a summary indicator derived from measures of income per capita, educational attainment, and fertility, to assess trends in LRI-related mortality. The two leading risk factors for LRI disability-adjusted life-years (DALYs), childhood undernutrition and air pollution, were used in a decomposition analysis to establish the relative contribution of changes in LRI DALYs. FINDINGS In 2015, we estimated that LRIs caused 2·74 million deaths (95% uncertainty interval [UI] 2·50 million to 2·86 million) and 103·0 million DALYs (95% UI 96·1 million to 109·1 million). LRIs have a disproportionate effect on children younger than 5 years, responsible for 704 000 deaths (95% UI 651 000-763 000) and 60.6 million DALYs (95ÙI 56·0-65·6). Between 2005 and 2015, the number of deaths due to LRI decreased by 36·9% (95% UI 31·6 to 42·0) in children younger than 5 years, and by 3·2% (95% UI -0·4 to 6·9) in all ages. Pneumococcal pneumonia caused 55·4% of LRI deaths in all ages, totalling 1 517 388 deaths (95% UI 857 940-2 183 791). Between 2005 and 2015, improvements in air pollution exposure were responsible for a 4·3% reduction in LRI DALYs and improvements in childhood undernutrition were responsible for an 8·9% reduction. INTERPRETATION LRIs are the leading infectious cause of death and the fifth-leading cause of death overall; they are the second-leading cause of DALYs. At the global level, the burden of LRIs has decreased dramatically in the last 10 years in children younger than 5 years, although the burden in people older than 70 years has increased in many regions. LRI remains a largely preventable disease and cause of death, and continued efforts to decrease indoor and ambient air pollution, improve childhood nutrition, and scale up the use of the pneumococcal conjugate vaccine in children and adults will be essential in reducing the global burden of LRI. FUNDING Bill & Melinda Gates Foundation.
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269
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Bauza V, Guest JS. The effect of young children's faeces disposal practices on child growth: evidence from 34 countries. Trop Med Int Health 2017; 22:1233-1248. [DOI: 10.1111/tmi.12930] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Valerie Bauza
- Department of Civil and Environmental Engineering University of Illinois at Urbana‐Champaign Urbana IL USA
| | - Jeremy S. Guest
- Department of Civil and Environmental Engineering University of Illinois at Urbana‐Champaign Urbana IL USA
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Amadi B, Besa E, Zyambo K, Kaonga P, Louis-Auguste J, Chandwe K, Tarr PI, Denno DM, Nataro JP, Faubion W, Sailer A, Yeruva S, Brantner T, Murray J, Prendergast AJ, Turner JR, Kelly P. Impaired Barrier Function and Autoantibody Generation in Malnutrition Enteropathy in Zambia. EBioMedicine 2017; 22:191-199. [PMID: 28750860 PMCID: PMC5552244 DOI: 10.1016/j.ebiom.2017.07.017] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 07/15/2017] [Accepted: 07/17/2017] [Indexed: 12/24/2022] Open
Abstract
Intestinal damage in malnutrition constitutes a threat to the survival of many thousands of children globally. We studied children in Lusaka, Zambia, with severe acute malnutrition (SAM) and persistent diarrhea using endoscopy, biopsy and analysis of markers and protective proteins in blood and intestinal secretions. We carried out parallel investigations in apparently healthy adults, and analyzed biomarkers only in apparently healthy children. Villus height and crypt depth did not differ in children with SAM and adult controls, but epithelial surface was reduced in children with SAM (median 445, interquartile range (IQR) 388, 562 μm per 100 μm muscularis mucosae) compared to adults (578, IQR 465,709; P = 0.004). Histological lesions and disruptions of claudin-4 and E-cadherin were most pronounced in children with SAM. Circulating lipopolysaccharide, a marker of bacterial translocation, was higher in malnourished children (251, IQR 110,460 EU/ml) than in healthy children (51, IQR 0,111; P = 0.0001). Other translocation markers showed similar patterns. Anti-Deamidated Gliadin Peptide IgG concentrations, although within the normal range, were higher in children with SAM (median 2.7 U/ml, IQR 1.5–8.6) than in adults (1.6, 1.4–2.1; P = 0.005), and were inversely correlated with villus height (ρ = − 0.79, n = 13, P = 0.001). Malnutrition enteropathy is associated with intestinal barrier failure and immune dysregulation. Enteropathy in children with severe acute malnutrition is characterized by variable villus blunting and epithelial disruption. Biomarkers indicate very high levels of microbial translocation from intestinal lumen to systemic circulation. Coeliac-type autoantibodies were associated with villus blunting, microbial translocation markers and mortality.
There is abundant evidence that childhood malnutrition is a major contributor to mortality in many low and middle income countries. Mortality remains unacceptably high. Here we show that severe acute malnutrition was characterized by very high levels of microbial translocation and inflammation, and severe mucosal damage with disturbed tight junction protein expression. Antibodies to tissue transglutaminase and deamidated gliadin peptides, although within the normal range, correlated with villus morphology, translocation markers and death. Malnutrition enteropathy permits mucosal inflammation, microbial translocation and immune dysregulation.
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Affiliation(s)
- Beatrice Amadi
- Department of Paediatrics, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia; Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Ellen Besa
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Kanekwa Zyambo
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Patrick Kaonga
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - John Louis-Auguste
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia; Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Kanta Chandwe
- Department of Paediatrics, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia
| | - Phillip I Tarr
- Department of Pediatrics, Washington University School of Medicine, St Louis, MO, USA
| | - Donna M Denno
- Department of Pediatrics, University of Washington, Seattle, USA
| | - James P Nataro
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, USA
| | | | - Anne Sailer
- Departments of Pathology and Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Sunil Yeruva
- Departments of Pathology and Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | | | - Andrew J Prendergast
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK
| | - Jerrold R Turner
- Departments of Pathology and Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Paul Kelly
- Tropical Gastroenterology and Nutrition Group, University of Zambia School of Medicine, Nationalist Road, Lusaka, Zambia; Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, London, UK.
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271
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Correlates of whole-blood polyunsaturated fatty acids among young children with moderate acute malnutrition. Nutr J 2017; 16:44. [PMID: 28705254 PMCID: PMC5508879 DOI: 10.1186/s12937-017-0264-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 06/25/2017] [Indexed: 01/18/2023] Open
Abstract
Background Severe acute malnutrition (SAM) has been associated with low polyunsaturated fatty acid (PUFA) status. However, investigations regarding PUFA status and correlates in children with moderate acute malnutrition (MAM) from low-income countries are scarce. The aim of this study was to describe whole-blood PUFA levels in children with moderate acute malnutrition (MAM) and to identify correlates of PUFAs. Methods We conducted a cross-sectional study using baseline data from a prospective nutritional intervention trial among 1609 children with MAM aged 6–23 months in Burkina Faso,West Africa. Whole-blood PUFAs were measured by gas chromatography and expressed as percent of total whole-blood fatty acids (FA%). Potential correlates of PUFAs including infection, inflammation, hemoglobin, anthropometry (difference between children diagnosed as having MAM based on low mid-upper-arm-circumference (MUAC) only, low MUAC and weight-for-height z-score (WHZ), or low WHZ only) and diet were assessed by linear regression adjusted for age and sex. Results Children with MAM had low concentrations of whole-blood PUFAs, particularly n-3 PUFAs. Moreover, children diagnosed with MAM based only on low MUAC had 0.32 (95% confidence interval (CI), 0.14; 0.50) and 0.40 (95% CI, 0.16; 0.63) FA% lower arachidonic acid (AA) than those recruited based on both low WHZ as well as low MUAC and those recruited with low WHZ only, respectively. Infection and inflammation were associated with low levels of all long-chain (LC)-PUFAs, while hemoglobin was positively associated with whole-blood LC-PUFAs. Conclusion While PUFA deficiency was not a general problem, overall whole-blood PUFA concentrations, especially of n-3 PUFAs, were low. Infection, inflammation, hemoglobin, anthropometry and diet were correlates of PUFAs concentrations in children with MAM. Trial registration The trial is registered at http://www.isrctn.com (ISRCTN42569496).
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272
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Abstract
PURPOSE OF REVIEW The term 'tropical enteropathy' originated in observations in the 1960s that small intestinal morphology and function differed in the tropics from the norms found in temperate climates. It was subsequently shown that this enteropathy is more closely related to environmental conditions than latitude, and it was re-labelled 'environmental enteropathy'. It is now recognised that environmental enteropathy (also now called environmental enteric dysfunction) has implications for the health and linear growth of children in low- and middle-income countries, and it may underlie poor responses to oral vaccination in these countries. The purpose of this review is to define and clarify this enteropathy despite the confusing terminology it has attracted and to contrast it with other enteropathic states. RECENT FINDINGS Recent work has begun to demonstrate the nature of the mucosal lesion and the relationship with microbial translocation which is currently thought to link a failure of mucosal barrier function and the cascade of systemic inflammation which inhibits growth. The evidence is still correlative rather than definitive, but derives some additional support from animal models. There are some common features between environmental enteropathy and other enteropathies, but there are important differences also. The mechanism of the link between enteropathy and vaccine failure is not understood, and neither is it clear how the more severe form of enteropathy, which we refer to as malnutrition enteropathy, is driven by nutrient depletion and intestinal infection. Tropical enteropathies form a group of disorders which include environmental and nutritional enteropathies. The long-term health implications of these disorders for health in low-income countries are just being explored, but the scale of their effects is very large, with millions of people affected.
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Affiliation(s)
- John Louis-Auguste
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, Newark Street, London, E1 2AT, UK
| | - Paul Kelly
- Blizard Institute, Barts & The London School of Medicine, Queen Mary University of London, Newark Street, London, E1 2AT, UK.
- TROPGAN, University of Zambia School of Medicine, University Teaching Hospital, Lusaka, Zambia.
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Saaka M, Galaa SZ. How is dietary diversity related to haematological status of preschool children in Ghana? Food Nutr Res 2017; 61:1333389. [PMID: 28659744 PMCID: PMC5475327 DOI: 10.1080/16546628.2017.1333389] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 05/15/2017] [Indexed: 12/04/2022] Open
Abstract
Background: The role of dietary diversity on blood biomarkers may be significant, but the evidence is limited. Objective: This study assessed the association between dietary diversity and haematological status of children aged 6-59 months controlling for various known confounders. Design: The analysis in this study is based on the 2014 Ghana Demographic and Health survey data.The study involved 2,388 pre-school children aged 6-59 months who constituted the sub-sample for anaemia assessment. Results: The mean haemoglobin concentration (Hb) was 10.2 g/dl ± 1.50 (95 % CI: 10.1 to 10.3), and anaemia prevalence (Hb < 11 g/dl) among children aged 6-59 months was 66.8 % (CI: 63.7 to 69.8). In multivariable logistic regression analysis,continued breastfeeding [Adjusted odds ratio (AOR) = 1.9 (95% CI: 1.19-2.91], 12-23 months of age (AOR = 2.4 (95% CI: 1.40-3.98), having fever in last two weeks (AOR = 1.7 (95% CI: 1.20-2.45, birth interval ≤ 24 months (AOR = 1.9 (1.20-2.84), and poorest wealth quintile (AOR = 2.6 (95% CI: 1.48-4.48) were positively associated with anaemia. Conclusion: The current study showed that factors other than poor dietary diversity predicted anaemia among children aged 6-59 months in Ghana.
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Affiliation(s)
- Mahama Saaka
- School of Allied Health Sciences, University for Development Studies, Tamale, Ghana
| | - Sylvester Zakaria Galaa
- Faculty of Integrated Development Studies, University for Development Studies, Tamale, Ghana
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274
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Estimates of global, regional, and national morbidity, mortality, and aetiologies of diarrhoeal diseases: a systematic analysis for the Global Burden of Disease Study 2015. THE LANCET. INFECTIOUS DISEASES 2017; 17:909-948. [PMID: 28579426 PMCID: PMC5589208 DOI: 10.1016/s1473-3099(17)30276-1] [Citation(s) in RCA: 727] [Impact Index Per Article: 103.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 03/15/2017] [Accepted: 03/23/2017] [Indexed: 02/07/2023]
Abstract
Background The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) provides an up-to-date analysis of the burden of diarrhoeal diseases. This study assesses cases, deaths, and aetiologies spanning the past 25 years and informs the changing picture of diarrhoeal disease worldwide. Methods We estimated diarrhoeal mortality by age, sex, geography, and year using the Cause of Death Ensemble Model (CODEm), a modelling platform shared across most causes of death in the GBD 2015 study. We modelled diarrhoeal morbidity, including incidence and prevalence, using a meta-regression platform called DisMod-MR. We estimated aetiologies for diarrhoeal diseases using a counterfactual approach that incorporates the aetiology-specific risk of diarrhoeal disease and the prevalence of the aetiology in diarrhoea episodes. We used the Socio-demographic Index, a summary indicator derived from measures of income per capita, educational attainment, and fertility, to assess trends in diarrhoeal mortality. The two leading risk factors for diarrhoea—childhood malnutrition and unsafe water, sanitation, and hygiene—were used in a decomposition analysis to establish the relative contribution of changes in diarrhoea disability-adjusted life-years (DALYs). Findings Globally, in 2015, we estimate that diarrhoea was a leading cause of death among all ages (1·31 million deaths, 95% uncertainty interval [95% UI] 1·23 million to 1·39 million), as well as a leading cause of DALYs because of its disproportionate impact on young children (71·59 million DALYs, 66·44 million to 77·21 million). Diarrhoea was a common cause of death among children under 5 years old (499 000 deaths, 95% UI 447 000–558 000). The number of deaths due to diarrhoea decreased by an estimated 20·8% (95% UI 15·4–26·1) from 2005 to 2015. Rotavirus was the leading cause of diarrhoea deaths (199 000, 95% UI 165 000–241 000), followed by Shigella spp (164 300, 85 000–278 700) and Salmonella spp (90 300, 95% UI 34 100–183 100). Among children under 5 years old, the three aetiologies responsible for the most deaths were rotavirus, Cryptosporidium spp, and Shigella spp. Improvements in safe water and sanitation have decreased diarrhoeal DALYs by 13·4%, and reductions in childhood undernutrition have decreased diarrhoeal DALYs by 10·0% between 2005 and 2015. Interpretation At the global level, deaths due to diarrhoeal diseases have decreased substantially in the past 25 years, although progress has been faster in some countries than others. Diarrhoea remains a largely preventable disease and cause of death, and continued efforts to improve access to safe water, sanitation, and childhood nutrition will be important in reducing the global burden of diarrhoea. Funding Bill & Melinda Gates Foundation.
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275
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Impact evaluation of different cash-based intervention modalities on child and maternal nutritional status in Sindh Province, Pakistan, at 6 mo and at 1 y: A cluster randomised controlled trial. PLoS Med 2017; 14:e1002305. [PMID: 28542506 PMCID: PMC5441577 DOI: 10.1371/journal.pmed.1002305] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2016] [Accepted: 04/12/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cash-based interventions (CBIs), offer an interesting opportunity to prevent increases in wasting in humanitarian aid settings. However, questions remain as to the impact of CBIs on nutritional status and, therefore, how to incorporate them into emergency programmes to maximise their success in terms of improved nutritional outcomes. This study evaluated the effects of three different CBI modalities on nutritional outcomes in children under 5 y of age at 6 mo and at 1 y. METHODS AND FINDINGS We conducted a four-arm parallel longitudinal cluster randomised controlled trial in 114 villages in Dadu District, Pakistan. The study included poor and very poor households (n = 2,496) with one or more children aged 6-48 mo (n = 3,584) at baseline. All four arms had equal access to an Action Against Hunger-supported programme. The three intervention arms were as follows: standard cash (SC), a cash transfer of 1,500 Pakistani rupees (PKR) (approximately US$14; 1 PKR = US$0.009543); double cash (DC), a cash transfer of 3,000 PKR; or a fresh food voucher (FFV) of 1,500 PKR; the cash or voucher amount was given every month over six consecutive months. The control group (CG) received no specific cash-related interventions. The median total household income for the study sample was 8,075 PKR (approximately US$77) at baseline. We hypothesized that, compared to the CG in each case, FFVs would be more effective than SC, and that DC would be more effective than SC-both at 6 mo and at 1 y-for reducing the risk of child wasting. Primary outcomes of interest were prevalence of being wasted (weight-for-height z-score [WHZ] < -2) and mean WHZ at 6 mo and at 1 y. The odds of a child being wasted were significantly lower in the DC arm after 6 mo (odds ratio [OR] = 0.52; 95% CI 0.29, 0.92; p = 0.02) compared to the CG. Mean WHZ significantly improved in both the FFV and DC arms at 6 mo (FFV: z-score = 0.16; 95% CI 0.05, 0.26; p = 0.004; DC: z-score = 0.11; 95% CI 0.00, 0.21; p = 0.05) compared to the CG. Significant differences on the primary outcome were seen only at 6 mo. All three intervention groups showed similar significantly lower odds of being stunted (height-for-age z-score [HAZ] < -2) at 6 mo (DC: OR = 0.39; 95% CI 0.24, 0.64; p < 0.001; FFV: OR = 0.41; 95% CI 0.25, 0.67; p < 0.001; SC: OR = 0.36; 95% CI 0.22, 0.59; p < 0.001) and at 1 y (DC: OR = 0.53; 95% CI 0.35, 0.82; p = 0.004; FFV: OR = 0.48; 95% CI 0.31, 0.73; p = 0.001; SC: OR = 0.54; 95% CI 0.36, 0.81; p = 0.003) compared to the CG. Significant improvements in height-for-age outcomes were also seen for severe stunting (HAZ < -3) and mean HAZ. An unintended outcome was observed in the FFV arm: a negative intervention effect on mean haemoglobin (Hb) status (-2.6 g/l; 95% CI -4.5, -0.8; p = 0.005). Limitations of this study included the inability to mask participants or data collectors to the different interventions, the potentially restrictive nature of the FFVs, not being able to measure a threshold effect for the two different cash amounts or compare the different quantities of food consumed, and data collection challenges given the difficult environment in which this study was set. CONCLUSIONS In this setting, the amount of cash given was important. The larger cash transfer had the greatest effect on wasting, but only at 6 mo. Impacts at both 6 mo and at 1 y were seen for height-based growth variables regardless of the intervention modality, indicating a trend toward nutrition resilience. Purchasing restrictions applied to food-based voucher transfers could have unintended effects, and their use needs to be carefully planned to avoid this. TRIAL REGISTRATION ISRCTN registry ISRCTN10761532.
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276
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Derso T, Tariku A, Biks GA, Wassie MM. Stunting, wasting and associated factors among children aged 6-24 months in Dabat health and demographic surveillance system site: A community based cross-sectional study in Ethiopia. BMC Pediatr 2017; 17:96. [PMID: 28376746 PMCID: PMC5379504 DOI: 10.1186/s12887-017-0848-2] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Accepted: 03/24/2017] [Indexed: 11/13/2022] Open
Abstract
Background Though there is a marked decline in burden of undernutrition, about 44 and 10% of children under five are stunted and wasted, respectively in Ethiopia. The highest prevalence of wasting occurs in young children (6–23 months), however literature are limited in these population groups. Therefore, this study aimed to assess stunting, wasting and associated factors among children aged 6–24 months in Dabat Health and Demographic Surveillance System (HDSS) site, northwest Ethiopia. Methods A community based cross-sectional study was conducted in Dabat HDSS site from May 01 to June 29, 2015. A total of 587 mother-child pairs were included in the study. A multivariate logistic regression analysis was carried out to identify factors associated with stunting and wasting, separately. Results The prevalence of stunting and wasting among children aged 6–24 months were 58.1 and 17.0%, respectively. Poor wealth status [Adjusted Odds Ratio (AOR) = 2.20; 95% Confidence Interval (CI): 1.42, 3.40], unavailability of latrine [AOR = 1.76; 95% CI: 1.17, 2.66], child age: 12–24 months [AOR = 3.24; 95% CI: 2.24, 4.69], not receiving maternal postnatal vitamin-A supplementation [AOR = 1.54; 95%: 1.02, 2.33] and source of family food: own food production [AOR = 1.71; 95% CI: 1.14, 2.57] were significantly associated with higher odds of stunting. However, only history of diarrheal morbidity was significantly associated with wasting [AOR = 2.06; 95% CI: 1.29, 3.30]. Conclusions In this community, the magnitude of stunting and wasting exists as a severe public health concern. Therefore, improving socio-economic status, latrine and maternal postnatal vitamin-supplementation coverage are essential to mitigate the high burden of stunting. Besides, reducing the childhood diarrheal morbidity as well as strengthening early diagnosis and management of the problem are crucial to curve the high prevalence of wasting.
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Affiliation(s)
- Terefe Derso
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Amare Tariku
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Gashaw Andargie Biks
- Department of Health Service Management and Heath Economics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Molla Mesele Wassie
- Department of Human Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Acevedo P, García Esteban MT, Lopez-Ejeda N, Gómez A, Marrodán MD. Influence of malnutrition upon all-cause mortality among children in Swaziland. ACTA ACUST UNITED AC 2017; 64:204-210. [PMID: 28417875 DOI: 10.1016/j.endinu.2017.01.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Revised: 01/09/2017] [Accepted: 01/14/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To analyze the effect of the type of malnutrition, sex, age and the presence of edema upon all-cause mortality in children under 5 years of age. MATERIAL AND METHODS A cross-sectional study was conducted during 2010 and 2011 in Swaziland. Sex, age, weight and height were taken to classify nutritional status according to the 2006 WHO growth standards: stunting (low height for age), wasting (low weight for height or low body mass index for age) and underweight (low weight for age). The sample (309 boys and 244 girls under 5 years of age) was analyzed by sex and age groups (under and equal/over 12 months). The association between variables was evaluated using the χ2 test. Cox regression analysis (HR, 95% CI) was used to assess the likelihood of mortality. RESULTS The mortality risk in malnourished children under one year of age was lower among females and increased in the presence of severe edema. Wasting combined with underweight increased the mortality risk in children under 12 months of age 5-fold, versus 11-fold in older children. The combination of stunting, wasting and underweight was closely associated to mortality. Stunting alone (not combined with wasting) did not significantly increase the mortality risk. CONCLUSIONS Sex, severe edema and wasting are predictors of mortality in malnourished children. Regardless of these factors, children with deficiencies referred to weight for height and weight for age present a greater mortality risk in comparison with children who present stunting only.
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Affiliation(s)
- Paula Acevedo
- Department of Biology, Faculty of Sciences, Autonomous University of Madrid, Spain
| | | | - Noemí Lopez-Ejeda
- Department of Zoology and Physical Anthropology, Faculty of Biological Sciences, Complutense University of Madrid, Spain; Research Group for Nutritional Epidemiology (EPINUT-UCM), Faculty of Medicine, Complutense University of Madrid, Spain
| | - Amador Gómez
- Technical Department, Action Against Hunger (ACF-Spain), Madrid, Spain
| | - María Dolores Marrodán
- Department of Zoology and Physical Anthropology, Faculty of Biological Sciences, Complutense University of Madrid, Spain; Research Group for Nutritional Epidemiology (EPINUT-UCM), Faculty of Medicine, Complutense University of Madrid, Spain; University Institute of Environmental Sciences, Complutense University of Madrid, Spain.
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Wright MJ, Mendez MA, Bentley ME, Adair LS. Breastfeeding modifies the impact of diarrhoeal disease on relative weight: a longitudinal analysis of 2-12 month-old Filipino infants. MATERNAL & CHILD NUTRITION 2017; 13:e12312. [PMID: 27062326 PMCID: PMC5882234 DOI: 10.1111/mcn.12312] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/10/2016] [Accepted: 02/11/2016] [Indexed: 10/22/2022]
Abstract
Undernutrition and diarrhoeal disease are major causes of infant mortality. We investigated the combined roles of breastfeeding and diarrhoea on infant size in 2940 infants from the Cebu Longitudinal Health and Nutrition Survey. The study aimed to assess whether breastfeeding status modified the deficits associated with diarrhoeal disease. The primary exposures were combinations of current breastfeeding status (yes/no), the presence of diarrhoeal disease in previous week (yes/no) and a categorical survey variable (six surveys taken at bimonthly intervals when infants were 2-12 months of age). Relative weight (weight-for-length z-scores), calculated using the WHO growth standards, was estimated using sex-stratified, fixed-effects longitudinal models that also adjusted for energy from complementary foods. Post-estimation Wald tests were conducted to identify subgroup differences in relative weight. Diarrhoea was associated with reduced relative weight in both breastfed and non-breastfed infants of 6-12 months. Diarrhoea-related deficits in relative weight were significantly exacerbated in non-breastfed girls of 6 and 8 months. Importantly, in infants <6 months, being breastfed and having diarrhoea was still associated with greater relative weight compared with being non-breastfed and diarrhoea-free. Breastfeeding emerged as a strong contributor to relative weight in younger infants (<6 months) while diarrhoeal disease strongly contributed to deficits in relative weight in older infants (6-12 months). These findings underscore the importance of breastfeeding for promoting infant nutritional status in infants with or without diarrhoea from birth to 12 months.
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Affiliation(s)
- Melecia J Wright
- Department of Nutrition, 135 Dauer DriveUniversity of North Carolina at Chapel HillChapel HillNorth Carolina27599USA
| | - Michelle A Mendez
- Department of Nutrition, 135 Dauer DriveUniversity of North Carolina at Chapel HillChapel HillNorth Carolina27599USA
| | - Margaret E Bentley
- Department of Nutrition, 135 Dauer DriveUniversity of North Carolina at Chapel HillChapel HillNorth Carolina27599USA
| | - Linda S Adair
- Department of Nutrition, 135 Dauer DriveUniversity of North Carolina at Chapel HillChapel HillNorth Carolina27599USA
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Saaka M, Aryee P, Kuganab-Lem R, Ali M, Masahudu AR. The effect of social behavior change communication package on maternal knowledge in obstetric danger signs among mothers in East Mamprusi District of Ghana. Global Health 2017; 13:19. [PMID: 28327154 PMCID: PMC5361799 DOI: 10.1186/s12992-017-0243-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2016] [Accepted: 03/08/2017] [Indexed: 11/26/2022] Open
Abstract
Background An understanding of maternal knowledge of the danger signs of obstetric and newborn complications is fundamental to attaining universal health coverage. In Northern Ghana, where maternal and newborn morbidity and mortality is high, little is known about the current knowledge level and associated determinants of these danger signs. This study assessed the effect of social behavior change communication (SBCC) package on knowledge of obstetric and newborn danger signs among mothers with children under 24 months of age. Methods This study used a non-randomized controlled community-based intervention design with pre and post-intervention household surveys in the intervention and comparison communities of the East Mamprusi District in Ghana. The study population were selected using a two-stage cluster sampling procedure. Result Only 521 (51.1%), 300 (29.4%) and 353 (34.6%) of the study participants knew at least three key danger signs during pregnancy, delivery and postpartum period respectively. The intervention had a positive effect on maternal knowledge of danger signs. Compared to their counterparts in the comparison communities, women in the intervention communities were about 2.6 times (AOR = 2. 58 [CI: 1.87, 3.57]), 3.4 times (AOR = 3.39 [CI: 2.31, 4.96]) and 2.2 times (AOR = 2.19 [CI: 1.68, 2.84]) more likely to have higher knowledge of danger signs of childbirth, postpartum and neonate, respectively. Having sought postnatal services at least once was significantly associated with the mentioning of at least three danger signs of postpartum (AOR = 3.90 [CI: 2.01, 7.58]) and childbirth (AOR = 1.75 [CI: 1.06, 2.85]). Conclusion There was a significant contribution of social and behavioral change communication as an intervention to maternal knowledge in obstetric danger signs after adjusting for confounding factors such as antenatal and post-natal care attendance. Therefore, provision of information, education and communication targeting women on danger signs of pregnancy and childbirth and associated factors would be an important step towards attaining universal health coverage.
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Affiliation(s)
- Mahama Saaka
- School of Allied Health Sciences, University for Development Studies, P O Box TL 1883, Tamale, Ghana.
| | - Paul Aryee
- School of Allied Health Sciences, University for Development Studies, P O Box TL 1883, Tamale, Ghana
| | - Robert Kuganab-Lem
- School of Allied Health Sciences, University for Development Studies, P O Box TL 1883, Tamale, Ghana
| | - Mohammed Ali
- 2Catholic Relief Services (Ghana) Program, Tamale, Ghana
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Huybregts L, Becquey E, Zongrone A, Le Port A, Khassanova R, Coulibaly L, Leroy JL, Rawat R, Ruel MT. The impact of integrated prevention and treatment on child malnutrition and health: the PROMIS project, a randomized control trial in Burkina Faso and Mali. BMC Public Health 2017; 17:237. [PMID: 28274214 PMCID: PMC5343313 DOI: 10.1186/s12889-017-4146-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 02/23/2017] [Indexed: 01/09/2023] Open
Abstract
Background Evidence suggests that both preventive and curative nutrition interventions are needed to tackle child acute malnutrition (AM) in developing countries. In addition to reducing the incidence of AM, providing preventive interventions may also help increase attendance (and coverage) of AM screening, a major constraint in the community-based management of child acute malnutrition (CMAM) model. There is a paucity of evidence-based strategies to deliver integrated preventive and curative interventions effectively and affordably at scale. The aim of the Innovative Approaches for the Prevention of Childhood Malnutrition (PROMIS) study is to assess the feasibility, quality of implementation, effectiveness and cost-effectiveness of an integrated child malnutrition prevention and treatment intervention package implemented through a community-based platform in Mali and a facility-based platform in Burkina Faso. Methods/Design The PROMIS intervention entails a comprehensive preventive package offered on a monthly basis to caregivers of children, while children are screened for acute malnutrition (AM). The package consists of behavior change communication on essential nutrition and hygiene actions, and monthly preventive doses of small quantity lipid-based nutrient supplements (SQ-LNS) for children aged 6 to 23.9 months. Positive AM cases are referred to treatment services offered by first-line health services according to the CMAM model. The PROMIS intervention will be evaluated using a mixed methods approach. The impact study encompasses two types of study design: i) repeated cross-sectional surveys conducted at baseline and at endline after 24 months of program implementation and ii) a longitudinal study with a monthly follow-up for 18 months. Primary study impact measures include the incidence and endpoint prevalence of AM, AM screening coverage and treatment compliance. A process evaluation will assess the feasibility and quality of implementation of the intervention guided by country specific program impact pathways (PIPs). Cost-effectiveness analysis will assess the economic feasibility of the intervention. Discussion The PROMIS study assesses the effectiveness of an innovative model to integrate prevention and treatment interventions for greater and more sustainable impacts on the incidence and prevalence of AM using a rigorous, theory-based randomized control trial approach. This type of programmatic research is urgently needed to help program implementers, policy makers, and investors prioritize, select and scale-up the best program models to prevent and treat AM and achieve the World Health Assembly goal of reducing childhood wasting to less than 5% globally by the year 2025. Trial registration Clinicaltrials.gov NCT02323815 (registered on December 18, 2014) and NCT02245152 (registered on September 16, 2014) Electronic supplementary material The online version of this article (doi:10.1186/s12889-017-4146-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lieven Huybregts
- International Food Policy Research Institute, 2033 K Street, NW, Washington, DC, 20006, USA.
| | - Elodie Becquey
- International Food Policy Research Institute, 2033 K Street, NW, Washington, DC, 20006, USA
| | - Amanda Zongrone
- International Food Policy Research Institute, 2033 K Street, NW, Washington, DC, 20006, USA
| | - Agnes Le Port
- International Food Policy Research Institute, 2033 K Street, NW, Washington, DC, 20006, USA
| | - Regina Khassanova
- Helen Keller International Burkina Faso country office, Ouagadougou, Burkina Faso
| | | | - Jef L Leroy
- International Food Policy Research Institute, 2033 K Street, NW, Washington, DC, 20006, USA
| | - Rahul Rawat
- International Food Policy Research Institute, 2033 K Street, NW, Washington, DC, 20006, USA
| | - Marie T Ruel
- International Food Policy Research Institute, 2033 K Street, NW, Washington, DC, 20006, USA
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Huda TM, Hayes A, El Arifeen S, Dibley MJ. Social determinants of inequalities in child undernutrition in Bangladesh: A decomposition analysis. MATERNAL AND CHILD NUTRITION 2017; 14. [PMID: 28271627 DOI: 10.1111/mcn.12440] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Revised: 01/18/2017] [Accepted: 01/25/2017] [Indexed: 11/29/2022]
Abstract
Socioeconomic inequalities in child undernutrition remain one of the main challenges in Bangladesh. The social determinants of health are mostly responsible for such inequalities across different population groups. However, no study has examined the relative contribution of different social determinants to the socioeconomic inequality in child undernutrition in Bangladesh. Our objective is to measure the extent of socioeconomic-related inequalities in childhood stunting and identify the key social determinants that potentially explain these inequalities in Bangladesh. We used data for children younger than 5 years of age for this analysis from 2 rounds of Bangladesh Demographic and Health Surveys conducted in 2004 and 2014. We examined the socioeconomic inequality in stunting using the concentration curve and concentration index. We then decomposed the concentration index into the contributions of individual social determinants. We found significant inequality in stunting prevalence. The negative concentration index of stunting indicated that stunting was more concentrated among the poor than among the well-off. Our results suggest that inequalities in stunting increased between 2004 and 2014. Household economic status, maternal and paternal education, health-seeking behavior of the mothers, sanitation, fertility, and maternal stature were the major contributors to the disparity in stunting prevalence in Bangladesh. Equity is a critical component of sustainable development goals. Health policymakers should work together across sectors and develop strategies for effective intersectoral actions to adequately address the social determinants of equity and reduce inequalities in stunting and other health outcomes.
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Affiliation(s)
- Tanvir M Huda
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia.,Maternal and Child Health Division, icddr,b, Dhaka, Bangladesh
| | - Alison Hayes
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
| | | | - Michael J Dibley
- Sydney School of Public Health, University of Sydney, Sydney, New South Wales, Australia
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282
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High Burden of Morbidity and Mortality but Not Growth Failure in Infants Exposed to but Uninfected with Human Immunodeficiency Virus in Tanzania. J Pediatr 2017; 180:191-199.e2. [PMID: 27829511 PMCID: PMC5183465 DOI: 10.1016/j.jpeds.2016.09.040] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/16/2016] [Accepted: 09/14/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To compare health and growth outcomes in children infected with HIV, children exposed to but uninfected with HIV, and children unexposed to HIV. STUDY DESIGN Our cohort included 3554 Tanzanian children enrolled in 2 trials of micronutrient supplementation. Among infants born to mothers infected with HIV, 264 were infected with HIV and 2088 were exposed to but uninfected at 6 weeks of age. An additional 1202 infants were unexposed to HIV. Infants were followed until 18 months of age, death, or loss to follow-up. Morbidity and growth were assessed at monthly nurse visits. RESULTS Compared with unexposed infants, hazard ratios (95% CI) for all-cause mortality in infants infected with HIV and infants who were exposed to but uninfected with HIV were 28.99 (14.83-56.66) and 2.79 (1.41-5.53), respectively, after adjusting for demographic and nutritional covariates. Compared with infants unexposed to HIV, infants infected with HIV also had a significantly greater risk of all measured morbidities, while infants who were exposed to but uninfected with HIV were significantly more likely to suffer from cough, fever, unscheduled outpatient visits, and hospitalizations. Infants infected with HIV also were more likely to experience stunting, wasting, and underweight at baseline and during follow-up. Infants exposed to but uninfected with HIV were more likely to be underweight at baseline (adjusted relative risk, 2.05; 95% CI, 1.45-2.89), but on average, experienced slower declines in height-for-age z-score, weight-for-age z-score, and weight-for-height z-score as well as a lower rate of stunting over follow-up, compared with unexposed infants. CONCLUSION In addition to preventing and treating HIV infection in infants, prevention-of-mother-to-child-transmission of HIV and child health services should also target children exposed to but uninfected with HIV to improve health outcomes in this vulnerable population. TRIAL REGISTRATION Clinicaltrials.gov: NCT00197730 and NCT00421668.
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283
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Bhandari N, Mohan SB, Bose A, Iyengar SD, Taneja S, Mazumder S, Pricilla RA, Iyengar K, Sachdev HS, Mohan VR, Suhalka V, Yoshida S, Martines J, Bahl R. Efficacy of three feeding regimens for home-based management of children with uncomplicated severe acute malnutrition: a randomised trial in India. BMJ Glob Health 2016; 1:e000144. [PMID: 28588982 PMCID: PMC5321385 DOI: 10.1136/bmjgh-2016-000144] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Revised: 11/30/2016] [Accepted: 12/01/2016] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To assess the efficacy of ready-to-use therapeutic food (RUTF), centrally produced RUTF (RUTF-C) or locally prepared RUTF (RUTF-L) for home-based management of uncomplicated severe acute malnutrition (SAM) compared with micronutrient-enriched (augmented) energy-dense home-prepared foods (A-HPF, the comparison group). METHODS In an individually randomised multicentre trial, we enrolled 906 children aged 6-59 months with uncomplicated SAM. The children enrolled were randomised to receive RUTF-C, RUTF-L or A-HPF. We provided foods, counselling and feeding support until recovery or 16 weeks, whichever was earlier and measured outcomes weekly (treatment phase). We subsequently facilitated access to government nutrition services and measured outcomes once 16 weeks later (sustenance phase). The primary outcome was recovery during treatment phase (weight-for-height ≥-2 SD and absence of oedema of feet). RESULTS Recovery rates with RUTF-L, RUTF-C and A-HPF were 56.9%, 47.5% and 42.8%, respectively. The adjusted OR was 1.71 (95% CI 1.20 to 2.43; p=0.003) for RUTF-L and 1.28 (95% CI 0.90 to 1.82; p=0.164) for RUTF-C compared with A-HPF. Weight gain in the RUTF-L group was higher than in the A-HPF group (adjusted difference 0.90 g/kg/day, 95% CI 0.30 to 1.50; p=0.003). Time to recovery was shorter in both RUTF groups. Morbidity was high and similar across groups. At the end of the study, the proportion of children with weight-for-height Z-score (WHZ) >-2 was similar (adjusted OR 1.12, 95% CI 0.74 to 1.95; p=0.464), higher for moderate malnutrition (WHZ<-2 and ≥-3; adjusted OR 1.46, 95% CI 1.02 to 2.08; p=0.039), and lower for those with SAM (adjusted OR 0.58, 95% CI 0.40 to 0.85; p=0.005) in the RUTF-L when compared with the A-HPF group. CONCLUSIONS This first randomised trial comparing options for home management of uncomplicated SAM confirms that RUTF-L is more efficacious than A-HPF at home. Recovery rates were lower than in African studies, despite longer treatment and greater support for feeding. TRIAL REGISTRATION NUMBER NCT01705769; Pre-results.
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Affiliation(s)
- Nita Bhandari
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | | | - Anuradha Bose
- Christian Medical College, Vellore, Tamil Nadu, India
| | - Sharad D Iyengar
- Action Research and Training for Health, Udaipur, Rajasthan, India
| | - Sunita Taneja
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | - Sarmila Mazumder
- Centre for Health Research and Development, Society for Applied Studies, New Delhi, India
| | | | - Kirti Iyengar
- Action Research and Training for Health, Udaipur, Rajasthan, India
| | | | | | - Virendra Suhalka
- Action Research and Training for Health, Udaipur, Rajasthan, India
| | - Sachiyo Yoshida
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland
| | - Jose Martines
- Centre for Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, Norway
| | - Rajiv Bahl
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organisation, Geneva, Switzerland
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Gough EK, Moodie EE, Prendergast AJ, Ntozini R, Moulton LH, Humphrey JH, Manges AR. Linear growth trajectories in Zimbabwean infants. Am J Clin Nutr 2016; 104:1616-1627. [PMID: 27806980 PMCID: PMC5118730 DOI: 10.3945/ajcn.116.133538] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 09/14/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Undernutrition in early life underlies 45% of child deaths globally. Stunting malnutrition (suboptimal linear growth) also has long-term negative effects on childhood development. Linear growth deficits accrue in the first 1000 d of life. Understanding the patterns and timing of linear growth faltering or recovery during this period is critical to inform interventions to improve infant nutritional status. OBJECTIVE We aimed to identify the pattern and determinants of linear growth trajectories from birth through 24 mo of age in a cohort of Zimbabwean infants. DESIGN We performed a secondary analysis of longitudinal data from a subset of 3338 HIV-unexposed infants in the Zimbabwe Vitamin A for Mothers and Babies trial. We used k-means clustering for longitudinal data to identify linear growth trajectories and multinomial logistic regression to identify covariates that were associated with each trajectory group. RESULTS For the entire population, the mean length-for-age z score declined from -0.6 to -1.4 between birth and 24 mo of age. Within the population, 4 growth patterns were identified that were each characterized by worsening linear growth restriction but varied in the timing and severity of growth declines. In our multivariable model, 1-U increments in maternal height and education and infant birth weight and length were associated with greater relative odds of membership in the least-growth restricted groups (A and B) and reduced odds of membership in the more-growth restricted groups (C and D). Male infant sex was associated with reduced odds of membership in groups A and B but with increased odds of membership in groups C and D. CONCLUSION In this population, all children were experiencing growth restriction but differences in magnitude were influenced by maternal height and education and infant sex, birth weight, and birth length, which suggest that key determinants of linear growth may already be established by the time of birth. This trial was registered at clinicaltrials.gov as NCT00198718.
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Affiliation(s)
- Ethan K Gough
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Erica Em Moodie
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Canada
| | - Andrew J Prendergast
- Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe.,Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Robert Ntozini
- Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe
| | - Lawrence H Moulton
- Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
| | - Jean H Humphrey
- Zvitambo Institute for Maternal Child Health Research, Harare, Zimbabwe.,Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD; and
| | - Amee R Manges
- School of Population and Public Health, University of British Columbia, Vancouver, Canada
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285
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Oddo VM, Christian P, Katz J, Liu L, Kozuki N, Black RE, Ntozini R, Humphrey J. Stunting Mediates the Association between Small-for-Gestational-Age and Postneonatal Mortality. J Nutr 2016; 146:2383-2387. [PMID: 27733526 PMCID: PMC5086790 DOI: 10.3945/jn.116.235457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 09/09/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND In sub-Saharan Africa, one-third of all births are small for gestational age (SGA), and 4.4 million children are stunted; both conditions increase the risk of child mortality. SGA has also been shown to increase the risk of stunting. OBJECTIVE We tested whether the association between SGA and postneonatal mortality is mediated by stunting. METHODS We used longitudinal data from children aged 6 wk to 24 mo (n = 12,155) enrolled in the ZVITAMBO (Zimbabwe Vitamin A for Mothers and Babies) trial. HIV exposure was defined based on maternal HIV status at baseline. SGA was defined as birthweight <10th percentile of the INTERGROWTH-21st (International Fetal and Newborn Growth Consortium for the 21st Century) standards. We used a standard mediation approach by comparing the attenuation of the risk when the mediator was added to the model. We used Cox proportional hazards models first to regress SGA on postneonatal mortality, controlling for age. Stunting (length-for-age z score <-2) was then included in the model to test mediation. RESULTS Approximately 20% of children were term SGA, and 23% were stunted before their last follow-up visit. In this cohort, 31% of children were exposed to HIV; the HIV-exposed group represented a pooled group of HIV-infected and HIV-exposed but uninfected children. Postneonatal mortality was significantly higher among children born SGA (HR: 1.5; 95% CI: 1.3, 1.7). This association was attenuated and not statistically significant when stunting was included in the model, suggesting a mediation effect (HR: 1.1; 95% CI: 0.91, 1.3). When stratified by HIV exposure status, we observed a significant attenuation of the risk, suggesting mediation, only among HIV-exposed children (model 1, HR: 1.3; 95% CI: 1.1, 1.6; model 2, HR: 1.1; 95% CI: 0.88, 1.3). CONCLUSIONS This analysis aids in investigating pathways that underlie an observed SGA-mortality relation and may inform survival interventions in undernourished settings.
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Affiliation(s)
| | - Parul Christian
- Departments of International Health and,Bill & Melinda Gates Foundation, Seattle, WA; and
| | | | - Li Liu
- Departments of International Health and,Population, Family, and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | | | - Robert Ntozini
- ZVITAMBO Institute for Maternal and Child Health Research, Harare, Zimbabwe
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286
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Andersen CT, Stein AD, Reynolds SA, Behrman JR, Crookston BT, Dearden KA, Penny ME, Schott W, Fernald LC. Stunting in Infancy Is Associated with Decreased Risk of High Body Mass Index for Age at 8 and 12 Years of Age. J Nutr 2016; 146:2296-2303. [PMID: 27683868 PMCID: PMC5086789 DOI: 10.3945/jn.116.234633] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 06/03/2016] [Accepted: 08/19/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Effects of early-life stunting on adiposity development later in childhood are not well understood, specifically with respect to age in the onset of overweight and obesity. OBJECTIVES We analyzed associations of infant stunting with prevalence of, incidence of, and reversion from high body mass index-for-age z score (BMIZ) later in life. We then estimated whether associations of infant stunting with BMIZ varied by sex, indigenous status, and rural or urban residence. METHODS Data were collected from 1942 Peruvian children in the Young Lives cohort study at ages 1, 5, 8, and 12 y. Multivariable generalized linear models estimated associations of stunting (height-for-age z score <-2) at age 1 y with risk of BMIZ > 1 and BMIZ > 2 prevalence, incidence (moving above a BMIZ threshold between ages), and reversion (moving below a BMIZ threshold between ages) at later ages. RESULTS After adjustment for covariates, stunting at age 1 y was associated with a lower prevalence of BMIZ > 1 at age 8 y (RR: 0.81; 95% CI: 0.66, 1.00; P = 0.049) and 12 y (RR: 0.75; 95% CI: 0.61, 0.91; P = 0.004), as well as a lower prevalence of BMIZ > 2 at age 8 y. Stunting was not associated with incident risk of BMIZ > 1 or BMIZ > 2. Stunting was positively associated at age 5 y with risk of reversion from BMIZ > 1 (RR: 1.22; 95% CI: 1.05, 1.42; P = 0.008) and BMIZ > 2. We found evidence that the association of stunting with prevalent and incident BMIZ > 1 was stronger for urban children at ages 5 and 8 y, and for nonindigenous children at age 8 y. CONCLUSIONS Stunting predicted a lower risk of prevalent BMIZ > 1 and BMIZ > 2, even after controlling for potential confounders. This finding may be driven in part by a higher risk of reversion from BMIZ > 1 by age 5 y. Our results contribute to an understanding of how nutritional stunting in infancy is associated with BMIZ later in life.
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Affiliation(s)
- Christopher T Andersen
- Division of Epidemiology and
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Aryeh D Stein
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA
| | - Sarah A Reynolds
- Division of Community Health and Human Development, School of Public Health, University of California, Berkeley, CA
| | - Jere R Behrman
- Department of Economics
- Department of Sociology, and
- Population Studies Center, University of Pennsylvania, Philadelphia, PA
| | | | | | | | - Whitney Schott
- Population Studies Center, University of Pennsylvania, Philadelphia, PA
| | - Lia Ch Fernald
- Division of Community Health and Human Development, School of Public Health, University of California, Berkeley, CA
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287
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Low mid-upper arm circumference identifies children with a high risk of death who should be the priority target for treatment. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0101-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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288
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Adu-Afarwuah S, Lartey A, Okronipa H, Ashorn P, Peerson JM, Arimond M, Ashorn U, Zeilani M, Vosti S, Dewey KG. Small-quantity, lipid-based nutrient supplements provided to women during pregnancy and 6 mo postpartum and to their infants from 6 mo of age increase the mean attained length of 18-mo-old children in semi-urban Ghana: a randomized controlled trial. Am J Clin Nutr 2016; 104:797-808. [PMID: 27534634 PMCID: PMC4997301 DOI: 10.3945/ajcn.116.134692] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Accepted: 07/07/2016] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Childhood stunting usually begins in utero and continues after birth; therefore, its reduction must involve actions across different stages of early life. OBJECTIVE We evaluated the efficacy of small-quantity, lipid-based nutrient supplements (SQ-LNSs) provided during pregnancy, lactation, and infancy on attained size by 18 mo of age. DESIGN In this partially double-blind, individually randomized trial, 1320 women at ≤20 wk of gestation received standard iron and folic acid (IFA group), multiple micronutrients (MMN group), or SQ-LNS (LNS group) daily until delivery, and then placebo, MMNs, or SQ-LNS, respectively, for 6 mo postpartum; infants in the LNS group received SQ-LNS formulated for infants from 6 to 18 mo of age (endline). The primary outcome was child length by 18 mo of age. RESULTS At endline, data were available for 85% of 1228 infants enrolled; overall mean length and length-for-age z score (LAZ) were 79.3 cm and -0.83, respectively, and 12% of the children were stunted (LAZ <-2). In analysis based on the intended treatment, mean ± SD length and LAZ for the LNS group (79.7 ± 2.9 cm and -0.69 ± 1.01, respectively) were significantly greater than for the IFA (79.1 ± 2.9 cm and -0.87 ± 0.99) and MMN (79.1 ± 2.9 cm and -0.91 ± 1.01) groups (P = 0.006 and P = 0.009, respectively). Differences were also significant for weight and weight-for-age z score but not head or midupper arm circumference, and the prevalence of stunting in the LNS group was 8.9%, compared with 13.7% in the IFA group and 12.9% in the MMN group (P = 0.12). In analysis based on actual supplement provided at enrollment, stunting prevalences were 8.9% compared with 15.1% and 11.5%, respectively (P = 0.045). CONCLUSION Provision of SQ-LNSs to women from pregnancy to 6 mo postpartum and to their infants from 6 to 18 mo of age may increase the child's attained length by age 18 mo in similar settings. This trial was registered at clinicaltrials.gov as NCT00970866.
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Affiliation(s)
- Seth Adu-Afarwuah
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana;
| | - Anna Lartey
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Harriet Okronipa
- Department of Nutrition and Food Science, University of Ghana, Legon, Accra, Ghana
| | - Per Ashorn
- Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | - Janet M Peerson
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA; and
| | - Mary Arimond
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA; and
| | - Ulla Ashorn
- Center for Child Health Research, University of Tampere School of Medicine and Tampere University Hospital, Tampere, Finland
| | | | - Stephen Vosti
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA; and
| | - Kathryn G Dewey
- Program in International and Community Nutrition, Department of Nutrition, University of California, Davis, Davis, CA; and
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289
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Semba RD, Trehan I, Gonzalez-Freire M, Kraemer K, Moaddel R, Ordiz MI, Ferrucci L, Manary MJ. Perspective: The Potential Role of Essential Amino Acids and the Mechanistic Target of Rapamycin Complex 1 (mTORC1) Pathway in the Pathogenesis of Child Stunting. Adv Nutr 2016; 7:853-65. [PMID: 27633102 PMCID: PMC5015042 DOI: 10.3945/an.116.013276] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Stunting is the best summary measure of chronic malnutrition in children. Approximately one-quarter of children under age 5 worldwide are stunted. Lipid-based or micronutrient supplementation has little to no impact in reducing stunting, which suggests that other critical dietary nutrients are missing. A dietary pattern of poor-quality protein is associated with stunting. Stunted children have significantly lower circulating essential amino acids than do nonstunted children. Inadequate dietary intakes of essential amino acids could adversely affect growth, because amino acids are required for synthesis of proteins. The master growth regulation pathway, the mechanistic target of rapamycin complex 1 (mTORC1) pathway, is exquisitely sensitive to amino acid availability. mTORC1 integrates cues such as nutrients, growth factors, oxygen, and energy to regulate growth of bone, skeletal muscle, nervous system, gastrointestinal tract, hematopoietic cells, immune effector cells, organ size, and whole-body energy balance. mTORC1 represses protein and lipid synthesis and cell and organismal growth when amino acids are deficient. Over the past 4 decades, the main paradigm for child nutrition in developing countries has been micronutrient malnutrition, with relatively less attention paid to protein. In this Perspective, we present the view that essential amino acids and the mTORC1 pathway play a key role in child growth. The current assumption that total dietary protein intake is adequate for growth among most children in developing countries needs re-evaluation.
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Affiliation(s)
- Richard D Semba
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD;
| | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | | | - Klaus Kraemer
- Sight and Life, Basel, Switzerland; and Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - M Isabel Ordiz
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | | | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
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290
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Cichon B, Fabiansen C, Yaméogo CW, Rytter MJH, Ritz C, Briend A, Christensen VB, Michaelsen KF, Oummani R, Filteau S, Ashorn P, Shepherd S, Friis H. Children with moderate acute malnutrition have inflammation not explained by maternal reports of illness and clinical symptoms: a cross-sectional study in Burkina Faso. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0096-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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291
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Tessema M, Gunaratna NS, Donato K, Cohen JL, McConnell M, Belayneh D, Brouwer ID, Belachew T, De Groote H. Translating the impact of quality protein maize into improved nutritional status for Ethiopian children: study protocol for a randomized controlled trial. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0089-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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292
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Semba RD, Zhang P, Gonzalez-Freire M, Moaddel R, Trehan I, Maleta KM, Ordiz MI, Ferrucci L, Manary MJ. The association of serum choline with linear growth failure in young children from rural Malawi. Am J Clin Nutr 2016; 104:191-7. [PMID: 27281303 PMCID: PMC4919529 DOI: 10.3945/ajcn.115.129684] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 05/04/2016] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Choline is an essential nutrient for cell structure, cell signaling, neurotransmission, lipid transport, and bone formation. Choline can be irreversibly converted to betaine, a major source of methyl groups. Trimethylene N-oxide (TMAO), a proatherogenic molecule, is produced from the metabolism of dietary choline by the gut microbiome. The relation between serum choline and its closely related metabolites with linear growth in children is unknown. OBJECTIVE The aim was to characterize the relation between serum choline and its closely related metabolites, betaine and TMAO, with linear growth and stunting in young children. DESIGN We measured serum choline, betaine, and TMAO concentrations by using liquid chromatography isotopic dilution tandem mass spectrometry in a cross-sectional study in 325 Malawian children, aged 12-59 mo, of whom 62% were stunted. RESULTS Median (25th, 75th percentile) serum choline, betaine, and TMAO concentrations were 6.4 (4.8, 8.3), 12.4 (9.1, 16.3), and 1.2 (0.7, 1.8) μmol/L, respectively. Spearman correlation coefficients of age with serum choline, betaine, and TMAO were -0.57 (P < 0.0001), -0.26 (P < 0.0001), and -0.10 (P = 0.07), respectively. Correlation coefficients of height-for-age z score with serum choline, betaine-to-choline ratio, and TMAO-to-choline ratio were 0.31 (P < 0.0001), -0.24 (P < 0.0001), and -0.29 (P < 0.0001), respectively. Serum choline concentrations were strongly and significantly associated with stunting. Children with and without stunting had median (25th, 75th percentile) serum choline concentrations of 5.6 (4.4, 7.4) and 7.3 (5.9, 9.1) μmol/L (P < 0.0001). CONCLUSIONS Linear growth failure in young children is associated with low serum choline and elevated betaine-to-choline and TMAO-to-choline ratios. Further work is needed to understand whether low dietary choline intake explains low circulating choline among stunted children living in low-income countries and whether increasing choline intake may correct choline deficiency and improve growth and development. This trial was registered in the ISRCTN registry (www.isrctn.com) as ISRCTN14597012.
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Affiliation(s)
- Richard D Semba
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD;
| | - Pingbo Zhang
- Wilmer Eye Institute, Johns Hopkins University School of Medicine, Baltimore, MD
| | | | | | - Indi Trehan
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO; and Departments of Community Health and Pediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - Kenneth M Maleta
- Community Health and Pediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
| | - M Isabel Ordiz
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO; and Departments of
| | | | - Mark J Manary
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO; and Departments of Community Health and Pediatrics and Child Health, University of Malawi College of Medicine, Blantyre, Malawi
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293
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Busert LK, Neuman M, Rehfuess EA, Dulal S, Harthan J, Chaube SS, Bhandari B, Costello H, Costello A, Manandhar DS, Saville NM. Dietary Diversity Is Positively Associated with Deviation from Expected Height in Rural Nepal. J Nutr 2016; 146:1387-93. [PMID: 27306894 PMCID: PMC4926845 DOI: 10.3945/jn.115.220137] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 05/02/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Recent research has highlighted the need for additional studies on the nutrition input required to stabilize growth. OBJECTIVE Our objective was to examine the association between dietary diversity and conditional growth in children aged 0-89 mo. METHODS We analyzed cohort data from 529 mothers and children living in a remote and food-insecure region in the mountains of Nepal. Children were aged 0-59 mo at baseline and were followed up after 9 and 29 mo. Conditional growth was calculated as the deviation from the expected height-for-age difference (HAD) trajectory based on previous measures of HAD and the pattern of growth in the population. Dietary diversity was assessed with the use of a count of the foods consumed from 7 food groups in the previous 7 d. The association between dietary diversity and conditional growth during the 2 follow-up periods (of 9 and 20 mo, respectively) was estimated with the use of ordinary least-squares regressions. RESULTS Prevalence of stunting and absolute height deficits was very high and increased over the course of the study. At the last measurement (age range 29-89 mo), 76.5% were stunted and the mean ± SD HAD was -11.7 ± 4.6 cm. Dietary diversity was associated positively with conditional growth in the later (May 2012-December 2013) but not the earlier (July 2011-May 2012) growth period. Children's ages ranged from 0 to 59 mo in July 2011, 9 to 69 mo in May 2012, and 29 to 89 mo in December 2013. After adjustment, increasing the dietary diversity by one food group was associated with a 0.09 cm (95% CI: 0.00, 0.17 cm) increase in conditional growth in the second growth period. CONCLUSIONS Increasing dietary diversity for children reduces the risk of stunting and improves growth after growth faltering. Future efforts should be directed at enabling families in food-insecure areas to feed their children a more diverse diet.
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Affiliation(s)
- Laura K Busert
- Institute for Medical Informatics, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany;
| | - Melissa Neuman
- Institute for Global Health, University College London, London, United Kingdom; and
| | - Eva A Rehfuess
- Institute for Medical Informatics, Biometry, and Epidemiology, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Sophiya Dulal
- Mother and Infant Research Activities, Kathmandu, Nepal
| | - Jayne Harthan
- Institute for Global Health, University College London, London, United Kingdom; and
| | | | | | - Harry Costello
- Institute for Global Health, University College London, London, United Kingdom; and
| | - Anthony Costello
- Institute for Global Health, University College London, London, United Kingdom; and
| | | | - Naomi M Saville
- Institute for Global Health, University College London, London, United Kingdom; and
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294
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Arndt MB, Richardson BA, Ahmed T, Mahfuz M, Haque R, John-Stewart GC, Denno DM, Petri WA, Kosek M, Walson JL. Fecal Markers of Environmental Enteropathy and Subsequent Growth in Bangladeshi Children. Am J Trop Med Hyg 2016; 95:694-701. [PMID: 27352872 DOI: 10.4269/ajtmh.16-0098] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 05/06/2016] [Indexed: 11/07/2022] Open
Abstract
Environmental enteropathy (EE), a subclinical intestinal disorder characterized by mucosal inflammation, reduced barrier integrity, and malabsorption, appears to be associated with increased risk of stunting in children in low- and middle-income countries. Fecal biomarkers indicative of EE (neopterin [NEO], myeloperoxidase [MPO], and alpha-1-antitrypsin [AAT]) have been negatively associated with 6-month linear growth. Associations between fecal markers (NEO, MPO, and AAT) and short-term linear growth were examined in a birth cohort of 246 children in Bangladesh. Marker concentrations were categorized in stool samples based on their distribution (< first quartile, interquartile range, > third quartile), and a 10-point composite EE score was calculated. Piecewise linear mixed-effects models were used to examine the association between markers measured quarterly (in months 3-21, 3-9, and 12-21) and 3-month change in length-for-age z-score (ΔLAZ). Children with high MPO levels at quarterly time points lost significantly more LAZ per 3-month period during the second year of life than those with low MPO (ΔLAZ = -0.100; 95% confidence interval = -0.167 to -0.032). AAT and NEO were not associated with growth; however, composite EE score was negatively associated with subsequent 3-month growth. In this cohort of children from an urban setting in Bangladesh, elevated MPO levels, but not NEO or AAT levels, were associated with decreases in short-term linear growth during the second year of life, supporting previous data suggesting the relevance of MPO as a marker of EE.
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Affiliation(s)
- Michael B Arndt
- Department of Epidemiology, University of Washington, Seattle, Washington.
| | - Barbra A Richardson
- Department of Biostatistics, University of Washington, Seattle, Washington. Department of Global Health, University of Washington, Seattle, Washington
| | - Tahmeed Ahmed
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Mustafa Mahfuz
- Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Rashidul Haque
- Parasitology Laboratory, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - Grace C John-Stewart
- Department of Epidemiology, University of Washington, Seattle, Washington. Department of Global Health, University of Washington, Seattle, Washington. Department of Medicine, University of Washington, Seattle, Washington. Department of Pediatrics, University of Washington, Seattle, Washington
| | - Donna M Denno
- Department of Global Health, University of Washington, Seattle, Washington. Department of Pediatrics, University of Washington, Seattle, Washington. Nutrition and Clinical Services Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), Dhaka, Bangladesh
| | - William A Petri
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia
| | - Margaret Kosek
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland. Asociación Benéfica Proyectos de Informática, Salud, Medicina, y Agricultura (PRISMA), Lima, Peru
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295
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Bourke CD, Berkley JA, Prendergast AJ. Immune Dysfunction as a Cause and Consequence of Malnutrition. Trends Immunol 2016; 37:386-398. [PMID: 27237815 PMCID: PMC4889773 DOI: 10.1016/j.it.2016.04.003] [Citation(s) in RCA: 361] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Revised: 03/31/2016] [Accepted: 04/06/2016] [Indexed: 12/13/2022]
Abstract
Malnutrition, which encompasses under- and overnutrition, is responsible for an enormous morbidity and mortality burden globally. Malnutrition results from disordered nutrient assimilation but is also characterized by recurrent infections and chronic inflammation, implying an underlying immune defect. Defects emerge before birth via modifications in the immunoepigenome of malnourished parents, and these may contribute to intergenerational cycles of malnutrition. This review summarizes key recent studies from experimental animals, in vitro models, and human cohorts, and proposes that immune dysfunction is both a cause and a consequence of malnutrition. Focusing on childhood undernutrition, we highlight gaps in current understanding of immune dysfunction in malnutrition, with a view to therapeutically targeting immune pathways as a novel means to reduce morbidity and mortality. Undernourished children principally die of common infections, and immune defects are consistently demonstrated in under- and overnutrition. Parental malnutrition leads to epigenetic modifications of infant immune and metabolic genes. Healthy gut development relies on sensing of dietary nutrients, commensal, and pathogenic microbes via immune receptors. Recurrent infections, chronic inflammation, and enteropathy compound clinical malnutrition by altering gut structure and function. Immune cell activation and systemic proinflammatory mediator levels are increased in malnutrition. Malnutrition impairs immune priming by DC and monocytes, and impairs effector memory T cell function. Immune dysfunction can directly drive pathological processes in malnutrition, including malabsorption, increased metabolic demand, dysregulation of the growth hormone and HPA axes, and greater susceptibility to infection.
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Affiliation(s)
- Claire D Bourke
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK.
| | - James A Berkley
- Kenya Medical Research Institute (KEMRI)-Wellcome Trust Collaborative Research Programme, Centre for Geographic Medicine Research, Kifili, Kenya; Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Andrew J Prendergast
- Centre for Genomics and Child Health, Blizard Institute, Queen Mary University of London, London, UK; Zvitambo Institute for Maternal and Child Health Research, Harare, Zimbabwe
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Sow SO, Muhsen K, Nasrin D, Blackwelder WC, Wu Y, Farag TH, Panchalingam S, Sur D, Zaidi AKM, Faruque ASG, Saha D, Adegbola R, Alonso PL, Breiman RF, Bassat Q, Tamboura B, Sanogo D, Onwuchekwa U, Manna B, Ramamurthy T, Kanungo S, Ahmed S, Qureshi S, Quadri F, Hossain A, Das SK, Antonio M, Hossain MJ, Mandomando I, Nhampossa T, Acácio S, Omore R, Oundo JO, Ochieng JB, Mintz ED, O’Reilly CE, Berkeley LY, Livio S, Tennant SM, Sommerfelt H, Nataro JP, Ziv-Baran T, Robins-Browne RM, Mishcherkin V, Zhang J, Liu J, Houpt ER, Kotloff KL, Levine MM. The Burden of Cryptosporidium Diarrheal Disease among Children < 24 Months of Age in Moderate/High Mortality Regions of Sub-Saharan Africa and South Asia, Utilizing Data from the Global Enteric Multicenter Study (GEMS). PLoS Negl Trop Dis 2016; 10:e0004729. [PMID: 27219054 PMCID: PMC4878811 DOI: 10.1371/journal.pntd.0004729] [Citation(s) in RCA: 177] [Impact Index Per Article: 22.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/02/2016] [Indexed: 11/18/2022] Open
Abstract
Background The importance of Cryptosporidium as a pediatric enteropathogen in developing countries is recognized. Methods Data from the Global Enteric Multicenter Study (GEMS), a 3-year, 7-site, case-control study of moderate-to-severe diarrhea (MSD) and GEMS-1A (1-year study of MSD and less-severe diarrhea [LSD]) were analyzed. Stools from 12,110 MSD and 3,174 LSD cases among children aged <60 months and from 21,527 randomly-selected controls matched by age, sex and community were immunoassay-tested for Cryptosporidium. Species of a subset of Cryptosporidium-positive specimens were identified by PCR; GP60 sequencing identified anthroponotic C. parvum. Combined annual Cryptosporidium-attributable diarrhea incidences among children aged <24 months for African and Asian GEMS sites were extrapolated to sub-Saharan Africa and South Asian regions to estimate region-wide MSD and LSD burdens. Attributable and excess mortality due to Cryptosporidium diarrhea were estimated. Findings Cryptosporidium was significantly associated with MSD and LSD below age 24 months. Among Cryptosporidium-positive MSD cases, C. hominis was detected in 77.8% (95% CI, 73.0%-81.9%) and C. parvum in 9.9% (95% CI, 7.1%-13.6%); 92% of C. parvum tested were anthroponotic genotypes. Annual Cryptosporidium-attributable MSD incidence was 3.48 (95% CI, 2.27–4.67) and 3.18 (95% CI, 1.85–4.52) per 100 child-years in African and Asian infants, respectively, and 1.41 (95% CI, 0.73–2.08) and 1.36 (95% CI, 0.66–2.05) per 100 child-years in toddlers. Corresponding Cryptosporidium-attributable LSD incidences per 100 child-years were 2.52 (95% CI, 0.33–5.01) and 4.88 (95% CI, 0.82–8.92) in infants and 4.04 (95% CI, 0.56–7.51) and 4.71 (95% CI, 0.24–9.18) in toddlers. We estimate 2.9 and 4.7 million Cryptosporidium-attributable cases annually in children aged <24 months in the sub-Saharan Africa and India/Pakistan/Bangladesh/Nepal/Afghanistan regions, respectively, and ~202,000 Cryptosporidium-attributable deaths (regions combined). ~59,000 excess deaths occurred among Cryptosporidium-attributable diarrhea cases over expected if cases had been Cryptosporidium-negative. Conclusions The enormous African/Asian Cryptosporidium disease burden warrants investments to develop vaccines, diagnostics and therapies. Cryptosporidium is a protozoan that causes diarrhea and malnutrition in young children in developing countries, and is associated with diarrhea cases and outbreaks in developed countries. To date, limited information exists on the burden of Cryptosporidium diarrheal disease in sub-Saharan Africa and South Asia, where most diarrheal disease deaths occur. We estimated the burden of Cryptosporidium-diarrhea and associated deaths in these regions using data from the Global Enteric Multicenter Study (GEMS). Cryptosporidium was associated with diarrhea mainly in children aged <24 months. Infections began in the first few months of life but clinical episodes of Cryptosporidium-associated diarrhea illness peaked at age 6–11 months. The annual number of Cryptosporidium-attributable diarrhea episodes was estimated at 2.9 and 4.7 million in children aged <24 months in sub-Saharan Africa and in the India/Pakistan/Bangladesh/Afghanistan/Nepal region of South Asia, respectively. In both regions combined, Cryptosporidium is estimated to contribute to approximately 202,000 deaths per year, and to ~59,000 more deaths in Cryptosporidium-attributable cases than if those cases had been negative for Cryptosporidium. Our study highlights the enormous burden attributable to Cryptosporidium in Africa and Asia, which underscores the need for developing vaccines and treatments to reduce this burden.
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Affiliation(s)
- Samba O. Sow
- Centre pour le Développement des Vaccins, Bamako, Mali
| | - Khitam Muhsen
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Dilruba Nasrin
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - William C. Blackwelder
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Yukun Wu
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Emergent Biosolutions, Gaithersburg, Maryland, United States of America
| | - Tamer H. Farag
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Sandra Panchalingam
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Dipika Sur
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Anita K. M. Zaidi
- Department of Paediatrics and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Abu S. G. Faruque
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh
| | - Debasish Saha
- Medical Research Council (United Kingdom) Unit, Fajara, Gambia
- GSK Vaccines, Wavre, Belgium
| | - Richard Adegbola
- Medical Research Council (United Kingdom) Unit, Fajara, Gambia
- GSK Vaccines, Wavre, Belgium
| | - Pedro L. Alonso
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | - Robert F. Breiman
- Global Disease Detection Division, Kenya Office of the US Centers for Disease Control and Prevention, Nairobi, Kenya
| | - Quique Bassat
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic—Universitat de Barcelona, Barcelona, Spain
| | | | - Doh Sanogo
- Centre pour le Développement des Vaccins, Bamako, Mali
| | | | - Byomkesh Manna
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | | | - Suman Kanungo
- National Institute of Cholera and Enteric Diseases, Kolkata, India
| | - Shahnawaz Ahmed
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh
| | - Shahida Qureshi
- Department of Paediatrics and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Farheen Quadri
- Department of Paediatrics and Child Health, the Aga Khan University, Karachi, Pakistan
| | - Anowar Hossain
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh
| | - Sumon K. Das
- International Centre for Diarrhoeal Disease Research, Mohakhali, Dhaka, Bangladesh
| | - Martin Antonio
- Medical Research Council (United Kingdom) Unit, Fajara, Gambia
| | | | - Inacio Mandomando
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Tacilta Nhampossa
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Sozinho Acácio
- Centro de Investigação em Saúde da Manhiça, Maputo, Mozambique
- Instituto Nacional de Saúde, Ministério de Saúde, Maputo, Mozambique
| | - Richard Omore
- Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Joseph O. Oundo
- Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya
| | - John B. Ochieng
- Kenya Medical Research Institute/Centers for Disease Control and Prevention, Kisumu, Kenya
| | - Eric D. Mintz
- Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Ciara E. O’Reilly
- Division of Foodborne, Waterborne and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Lynette Y. Berkeley
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Sofie Livio
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Sharon M. Tennant
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Halvor Sommerfelt
- Centre of Intervention Science in Maternal and Child Health, Centre for International Health, University of Bergen, Bergen, and Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway
| | - James P. Nataro
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Tomer Ziv-Baran
- Department of Epidemiology and Preventive Medicine, School of Public Health, Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Roy M. Robins-Browne
- Department of Microbiology and Immunology, The University of Melbourne, Murdoch Children’s Research Institute, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Vladimir Mishcherkin
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Jixian Zhang
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - Jie Liu
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - Eric R. Houpt
- Division of Infectious Diseases and International Health, Department of Medicine, University of Virginia, Charlottesville, Virginia, United States of America
| | - Karen L. Kotloff
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
| | - Myron M. Levine
- Center for Vaccine Development, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, United States of America
- * E-mail:
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297
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Greffeuille V, Sophonneary P, Laillou A, Gauthier L, Hong R, Hong R, Poirot E, Dijkhuizen M, Wieringa F, Berger J. Persistent Inequalities in Child Undernutrition in Cambodia from 2000 until Today. Nutrients 2016; 8:nu8050297. [PMID: 27196924 PMCID: PMC4882710 DOI: 10.3390/nu8050297] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 04/27/2016] [Accepted: 05/09/2016] [Indexed: 11/18/2022] Open
Abstract
The study assessed the trends of nutritional status of children under age five in Cambodia over four DHS surveys from 2000 to 2014 and the contribution of socioeconomic and demographic factors to its changes. Undernutrition was a public health problem in all surveys. Despite consistent improvement over the years, stunting still affected 32.5% of children in 2014. Wasting prevalence did not improve since 2005 and affected 9.6% of children under five in 2014. Low wealth and mother education; and rural residence contributed to undernutrition. In 2014; wealth status was the main socioeconomic factor associated with undernutrition and the nutritional status of children was strongly related to that of their mothers. Anemia prevalence was high and after a decrease between 2000 and 2005 remained at 45%. The prevalence of overweight was less than 10% and did not change over the years despite an increasing trend in the richest households of urban areas. Persistent inequalities in child undernutrition call for action, giving priority to the most vulnerable households to ensure availability and access to nutrient-rich foods for women and children through nutrition-sensitive and nutrition-specific programs. The recent increase of overweight in the richest populations must also be considered in Cambodian health policies.
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Affiliation(s)
| | - Prak Sophonneary
- National Nutrition Program, Maternal and Child Health Center, No. 31A, Rue de France (St. 47), Phnom Penh 12202, Cambodia.
| | - Arnaud Laillou
- United Nations Children's Emergency Fund, Maternal, Newborn and Child Health and Nutrition Section, No. 11 Street 75, Phnom Penh 12202, Cambodia.
| | - Ludovic Gauthier
- JRU NUTRIPASS IRD-SupAgro-UM, 911 av Agropolis, Montpellier 34000, France.
| | - Rathmony Hong
- United Nations Children's Emergency Fund, Maternal, Newborn and Child Health and Nutrition Section, No. 11 Street 75, Phnom Penh 12202, Cambodia.
| | - Rathavuth Hong
- Inner City Found International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA.
| | - Etienne Poirot
- United Nations Children's Emergency Fund, Maternal, Newborn and Child Health and Nutrition Section, No. 11 Street 75, Phnom Penh 12202, Cambodia.
| | - Marjoleine Dijkhuizen
- Department of Human Nutrition, Copenhagen University, Rolighedsvej 26, Frederiksberg 1958, Denmark.
| | - Frank Wieringa
- JRU NUTRIPASS IRD-SupAgro-UM, 911 av Agropolis, Montpellier 34000, France.
| | - Jacques Berger
- JRU NUTRIPASS IRD-SupAgro-UM, 911 av Agropolis, Montpellier 34000, France.
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298
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Moench-Pfanner R, Silo S, Laillou A, Wieringa F, Hong R, Hong R, Poirot E, Bagriansky J. The Economic Burden of Malnutrition in Pregnant Women and Children under 5 Years of Age in Cambodia. Nutrients 2016; 8:E292. [PMID: 27187462 PMCID: PMC4882705 DOI: 10.3390/nu8050292] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 04/27/2016] [Accepted: 05/10/2016] [Indexed: 11/20/2022] Open
Abstract
Malnutrition is locked in a vicious cycle of increased mortality, poor health, impaired cognitive development, slow physical growth, reduced learning capacity, inferior performance, and ultimately lower adult work performance and productivity. The consensus of global scientific evidence indicates that lowering the rates of malnutrition will be an indispensable component of any successful program to raise the quality of human capital and resources. This study used a "consequence model" to apply the coefficient risk-deficit on economic losses, established in the global scientific literature, to Cambodian health, demographic, and economic data to develop a national estimate of the value of economic losses due to malnutrition. The impact of the indicators of malnutrition analyzed represent a burden to the national economy of Cambodia estimated at 266 million USD annually (1.7% of GDP). Stunting is reducing the Cambodian economic output by more than 120 million USD, and iodine deficiency disorders alone by 57 million USD. This economic burden is too high in view of Cambodia's efforts to drive economic development. The government should rapidly expand a range of low-cost effective nutrition interventions to break the current cycle of increased mortality, poor health and ultimately lower work performance, productivity, and earnings.
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Affiliation(s)
- Regina Moench-Pfanner
- Ibn360 Pte Ltd., 3 Pickering Street, 02-36 Nankin Row, China Square Central, Singapore 048660, Singapore.
| | - Sok Silo
- Office of the Council of Minister, Council of Agriculture of Rural Development, Russian Federation Blvd, Phnom Penh 12100, Cambodia.
| | - Arnaud Laillou
- United Nations Children's Emergency Fund, Maternal, Newborn and Child Health and Nutrition section, no11 street 75, 12202 Phnom Penh, Cambodia.
| | - Frank Wieringa
- Institute of Research for Development (IRD), UMR Nutripass IRD-UM2-UM1, 34000 Montpellier, France.
| | - Rathamony Hong
- United Nations Children's Emergency Fund, Maternal, Newborn and Child Health and Nutrition section, no11 street 75, 12202 Phnom Penh, Cambodia.
| | - Rathavuth Hong
- ICF International, 530 Gaither Road, Suite 500, Rockville, MD 20850, USA.
| | - Etienne Poirot
- Office of the Council of Minister, Council of Agriculture of Rural Development, Russian Federation Blvd, Phnom Penh 12100, Cambodia.
| | - Jack Bagriansky
- Independent Consultant, 606 Park Lane, Decatur, GA 30033, USA.
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299
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Stevens GA, Bennett JE, Hennocq Q, Lu Y, De-Regil LM, Rogers L, Danaei G, Li G, White RA, Flaxman SR, Oehrle SP, Finucane MM, Guerrero R, Bhutta ZA, Then-Paulino A, Fawzi W, Black RE, Ezzati M. Trends and mortality effects of vitamin A deficiency in children in 138 low-income and middle-income countries between 1991 and 2013: a pooled analysis of population-based surveys. LANCET GLOBAL HEALTH 2016; 3:e528-36. [PMID: 26275329 DOI: 10.1016/s2214-109x(15)00039-x] [Citation(s) in RCA: 311] [Impact Index Per Article: 38.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 04/15/2015] [Accepted: 04/29/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Vitamin A deficiency is a risk factor for blindness and for mortality from measles and diarrhoea in children aged 6-59 months. We aimed to estimate trends in the prevalence of vitamin A deficiency between 1991 and 2013 and its mortality burden in low-income and middle-income countries. METHODS We collated 134 population-representative data sources from 83 countries with measured serum retinol concentration data. We used a Bayesian hierarchical model to estimate the prevalence of vitamin A deficiency, defined as a serum retinol concentration lower than 0·70 μmol/L. We estimated the relative risks (RRs) for the effects of vitamin A deficiency on mortality from measles and diarrhoea by pooling effect sizes from randomised trials of vitamin A supplementation. We used information about prevalences of deficiency, RRs, and number of cause-specific child deaths to estimate deaths attributable to vitamin A deficiency. All analyses included a systematic quantification of uncertainty. FINDINGS In 1991, 39% (95% credible interval 27-52) of children aged 6-59 months in low-income and middle-income countries were vitamin A deficient. In 2013, the prevalence of deficiency was 29% (17-42; posterior probability [PP] of being a true decline=0·81). Vitamin A deficiency significantly declined in east and southeast Asia and Oceania from 42% (19-70) to 6% (1-16; PP>0·99); a decline in Latin America and the Caribbean from 21% (11-33) to 11% (4-23; PP=0·89) also occurred. In 2013, the prevalence of deficiency was highest in sub-Saharan Africa (48%; 25-75) and south Asia (44%; 13-79). 94 500 (54 200-146 800) deaths from diarrhoea and 11 200 (4300-20 500) deaths from measles were attributable to vitamin A deficiency in 2013, which accounted for 1·7% (1·0-2·6) of all deaths in children younger than 5 years in low-income and middle-income countries. More than 95% of these deaths occurred in sub-Saharan Africa and south Asia. INTERPRETATION Vitamin A deficiency remains prevalent in south Asia and sub-Saharan Africa. Deaths attributable to this deficiency have decreased over time worldwide, and have been almost eliminated in regions other than south Asia and sub-Saharan Africa. This new evidence for both prevalence and absolute burden of vitamin A deficiency should be used to reconsider, and possibly revise, the list of priority countries for high-dose vitamin A supplementation such that a country's priority status takes into account both the prevalence of deficiency and the expected mortality benefits of supplementation. FUNDIN Bill & Melinda Gates Foundation, Grand Challenges Canada, UK Medical Research Council.
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Affiliation(s)
- Gretchen A Stevens
- Department of Health Statistics and Information Systems, World Health Organization, Geneva, Switzerland
| | - James E Bennett
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Quentin Hennocq
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Yuan Lu
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA
| | | | - Lisa Rogers
- Department of Nutrition for Health and Development, World Health Organization, Geneva, Switzerland
| | - Goodarz Danaei
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Guangquan Li
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK
| | - Richard A White
- Department of Infectious Disease Epidemiology, Division of Infectious Disease Control and Department of Health Statistics, Division of Epidemiology, Norwegian Institute of Public Health, Oslo, Norway
| | - Seth R Flaxman
- School of Computer Science & Heinz College, Carnegie Mellon University, Pittsburgh, PA, USA
| | | | | | - Ramiro Guerrero
- PROESA-Research Center for Social Protection and Health Economics, Universidad Icesi, Cali, Colombia
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; Centre for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Wafaie Fawzi
- Department of Global Health and Population, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Epidemiology, Harvard T H Chan School of Public Health, Boston, MA, USA; Department of Nutrition, Harvard School of Public Health, Boston, MA, USA
| | - Robert E Black
- Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD, USA
| | - Majid Ezzati
- MRC-PHE Centre for Environment and Health, School of Public Health, Imperial College London, London, UK.
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300
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de Onis M, Branca F. Childhood stunting: a global perspective. MATERNAL & CHILD NUTRITION 2016; 12 Suppl 1:12-26. [PMID: 27187907 PMCID: PMC5084763 DOI: 10.1111/mcn.12231] [Citation(s) in RCA: 569] [Impact Index Per Article: 71.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 08/28/2015] [Accepted: 09/09/2015] [Indexed: 12/25/2022]
Abstract
Childhood stunting is the best overall indicator of children's well-being and an accurate reflection of social inequalities. Stunting is the most prevalent form of child malnutrition with an estimated 161 million children worldwide in 2013 falling below -2 SD from the length-for-age/height-for-age World Health Organization Child Growth Standards median. Many more millions suffer from some degree of growth faltering as the entire length-for-age/height-for-age z-score distribution is shifted to the left indicating that all children, and not only those falling below a specific cutoff, are affected. Despite global consensus on how to define and measure it, stunting often goes unrecognized in communities where short stature is the norm as linear growth is not routinely assessed in primary health care settings and it is difficult to visually recognize it. Growth faltering often begins in utero and continues for at least the first 2 years of post-natal life. Linear growth failure serves as a marker of multiple pathological disorders associated with increased morbidity and mortality, loss of physical growth potential, reduced neurodevelopmental and cognitive function and an elevated risk of chronic disease in adulthood. The severe irreversible physical and neurocognitive damage that accompanies stunted growth poses a major threat to human development. Increased awareness of stunting's magnitude and devastating consequences has resulted in its being identified as a major global health priority and the focus of international attention at the highest levels with global targets set for 2025 and beyond. The challenge is to prevent linear growth failure while keeping child overweight and obesity at bay.
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Affiliation(s)
- Mercedes de Onis
- Department of Nutrition for Health and DevelopmentWorld Health OrganizationGenevaSwitzerland
| | - Francesco Branca
- Department of Nutrition for Health and DevelopmentWorld Health OrganizationGenevaSwitzerland
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