Design of the South East Asian Nutrition Survey (SEANUTS): a four-country multistage cluster design study

Primary School-Aged Children's Physical Activity Level, Eating Habit, and Sleeping Pattern Changes During the COVID-19 Pandemic in Indonesia

Background and objective This study aims to explore the effect of physical distancing on physical activity, eating habits, and sleeping patterns among Indonesian primary schoolchildren during the COVID-19 pandemic. Methodology This cross-sectional study was conducted from October to December 2020, involving 489 primary schoolchildren. Parents/caregivers were queried about changes in their children's physical activity (utilizing the Physical Activity Questionnaire for Older Children - PAQ-C), eating habits (via a questionnaire modified from Southeast Asian Nutrition Surveys - SEANUTS), and sleeping patterns (assessed using the Children's Sleep Habits Questionnaire - CSHQ) both before and during the pandemic. Various sociodemographic characteristics and income status were also obtained. Paired univariate and multivariate analyses were conducted where applicable. Results In comparison to the period before the pandemic, both the PAQ-C score and active proportion significantly decreased during the pandemic (P = 0.000). Children consumed more snacks (322, 65.8%) but less canned and processed foods (180, 36.8%, and 128, 26.2%, respectively). Sleep duration and sufficiency increased significantly, with a CSHQ score mean of 48.62 ± 9.88 (P = 0.000, P = 0.004), and sleep disturbance was observed in 391 (79.96%) subjects. Conclusions Children were physically less active during the COVID-19 pandemic. They also experienced variable changes in eating habits based on parental employment, family income and expenses, and the presence of governmental support. While more children had longer sleep duration and more achieved the recommended sleep time, sleep disturbance happened in most subjects.

Vitamin D deficiency in South-East Asian children: a systematic review

OBJECTIVE

To describe the prevalence and determinants of vitamin D deficiency (VDD) among healthy children aged between 0 and 18 years living in South-East Asia (SEA).

DESIGN

We systematically searched Ovid MEDLINE and Ovid EMBASE for observational studies assessing VDD among healthy children in the SEA region as the primary or secondary outcome from database inception to 6 April 2021. PubMed was used for e-pubs and publications not indexed in Medline. Publications that included abstracts in English were included. We performed a systematic review to describe the prevalence of VDD in SEA children.

RESULTS

Our initial search identified 550 publications with an additional 2 publications from manual screening. Of those, 21 studies from 5 different countries (Thailand, Indonesia, Vietnam, Malaysia and Cambodia) were summarised and included in forest plots. The prevalence of VDD (<50 nmol/L) ranged from 0.9% to 96.4%, with >50% of newborns having VDD, and severe VDD (<30 nmol/L) ranged from 0% to 55.8%. Female sex and urban living were the most common determinants of VDD.

CONCLUSIONS

VDD among healthy children living in the SEA region is common. Efforts to detect VDD and the implementation of preventive measures, including education on safe sun exposure and oral vitamin D supplementation or food fortification, should be considered for key target groups, including adolescent females and pregnant and lactating women to improve the vitamin D status of newborns.

PROTOCOL REGISTRATION NUMBER

This study is registered with PROSPERO (CRD42020181600).

Micronutrient Deficiencies and Stunting Were Associated with Socioeconomic Status in Indonesian Children Aged 6-59 Months

Micronutrient deficiencies and stunting are known as a significant problem in most developing countries, including Indonesia. The objective of this study was to analyze the association between micronutrient deficiencies and stunting with socioeconomic status (SES) among Indonesian children aged 6–59 months. This cross-sectional study was part of the South East Asian Nutrition Surveys (SEANUTS). A total of 1008 Indonesian children were included in the study. Anemia, iron deficiency, vitamin A deficiency, vitamin D deficiency, and stunting were identified in this study. Structured questionnaires were used to measure SES. Differences between micronutrient parameters and anthropometric indicators with the SES groups were tested using one-way ANOVA with post-hoc test after adjusted for age, area resident (rural and urban), and sex. The highest prevalence of anemia, stunting, and severe stunting were found to be most significant in the lowest SES group at 45.6%, 29.3%, and 54.5%, respectively. Children from the lowest SES group had significantly lower means of Hb, ferritin, retinol, and HAZ. Severely stunted children had a significantly lower mean of Hb concentration compared to stunted and normal height children. Micronutrient deficiencies, except vitamin D, and stunting, were associated with low SES among Indonesian children aged 6–59 months.

Calcium Consumption During Pregnancy: A Multicenter Study in a Middle-Income Country in Southeast Asia

Objective

To perform a cross-sectional observational study of calcium consumption among pregnant women from multicenter tertiary care hospitals in the middle-income country in Southeast Asia.

Study Design

A cross-sectional observational study.

Setting

The study was conducted in four geographical regions (northern, northeastern, southern, and central) of Thailand. Five participating hospitals consisted of one university hospital in each region and one additional tertiary care hospital in the central region.

Materials and Methods

A cross-sectional study was performed nationwide from 1st November 2017 to 31st January 2019. All singleton aged 19-40 years were included. Exclusion criteria were any conditions that influenced calcium-containing food consumption. Dietary intake self-records immediately after eating for two working days and one holiday were analyzed via INMUCAL-NV3.0 dietary program.

Results

The 1549 records were obtained. The mean age was 29 ± 5.7 years. Most participants were primigravida (48.6%). The average gestational age was 20.6 ± 8.8 weeks. Mean calcium consumption was 602.4 mg/day (95% CI; 589.2615.6 mg/day) mg/dL. Inadequate calcium consumption prevalence based on the Thai dietary reference intake (less than 800 mg/day) and US Institute of Medicine (less than 1000 mg/day) were 82.0% and 93.4%, respectively.

Conclusion

The mean calcium consumption among pregnant women in the middle-income country in Southeast Asia was 602.4 mg/day (95% CI 589.2-615.6 mg/day). Inadequate calcium consumption of Thai pregnant women prevalence was 82.0% and 93.4% according to Thai dietary reference intake in pregnancy and the US Institute of Medicine.

Stunting Was Associated with Reported Morbidity, Parental Education and Socioeconomic Status in 0.5-12-Year-Old Indonesian Children

Stunting is highly prevalent in Indonesian children. The objective of this study was to identify the associations of stunting with morbidity, parental education and socioeconomic status (SES) in Indonesian children. The study population was part of the South East Asian Nutrition Surveys (SEANUTS). A total of 2236 Indonesian children aged 0.5 to 12 years, who had participated in the SEANUTS, were included in this study. Stunting was defined as height for age Z-score (HAZ) ≤ −2 using WHO criteria and severe stunting as HAZ ≤ −3. Information on morbidity, parental education and family SES were collected by structured questionnaires. ANOVA was used for evaluating differences across groups, with or without correction for confounders. The results showed that the overall prevalence of stunting was 31.4%. HAZ in stunted children was associated with disease incidence, including frequency, parental education and family income. There were no significant differences in HAZ values in stunted children with one or more bouts of infectious, digestive tract or respiratory tract illnesses compared to stunted children with no reported illness. The prevalence of stunting in Indonesian children was high and was strongly associated with child morbidity, parental education and SES.

Low socioeconomic status and severe obesity are linked to poor cognitive performance in Malaysian children

Background

Socioeconomic factors and nutritional status have been associated with childhood cognitive development. However, previous Malaysian studies had been conducted with small populations and had inconsistent results. Thus, this present study aims to determine the association between socioeconomic and nutritional status with cognitive performance in a nationally representative sample of Malaysian children.

Methods

A total of 2406 Malaysian children aged 5 to 12 years, who had participated in the South East Asian Nutrition Surveys (SEANUTS), were included in this study. Cognitive performance [non-verbal intelligence quotient (IQ)] was measured using Raven’s Progressive Matrices, while socioeconomic characteristics were determined using parent-report questionnaires. Body mass index (BMI) was calculated using measured weight and height, while BMI-for-age Z-score (BAZ) and height-for-age Z-score (HAZ) were determined using WHO 2007 growth reference.

Results

Overall, about a third (35.0%) of the children had above average non-verbal IQ (high average: 110–119; superior: ≥120 and above), while only 12.2% were categorized as having low/borderline IQ (< 80). Children with severe obesity (BAZ > 3SD), children from very low household income families and children whose parents had only up to primary level education had the highest prevalence of low/borderline non-verbal IQ, compared to their non-obese and higher socioeconomic counterparts. Parental lack of education was associated with low/borderline/below average IQ [paternal, OR = 2.38 (95%CI 1.22, 4.62); maternal, OR = 2.64 (95%CI 1.32, 5.30)]. Children from the lowest income group were twice as likely to have low/borderline/below average IQ [OR = 2.01 (95%CI 1.16, 3.49)]. Children with severe obesity were twice as likely to have poor non-verbal IQ than children with normal BMI [OR = 2.28 (95%CI 1.23, 4.24)].

Conclusions

Children from disadvantaged backgrounds (that is those from very low income families and those whose parents had primary education or lower) and children with severe obesity are more likely to have poor non-verbal IQ. Further studies to investigate the social and environmental factors linked to cognitive performance will provide deeper insights into the measures that can be taken to improve the cognitive performance of Malaysian children.

Validation of a semi-quantitative FFQ for 18-month-old toddlers: the Growing Up in Singapore Towards Healthy Outcomes (GUSTO) study

OBJECTIVE

Dietary intake of toddlers has been of growing interest due to its long-term consequences on health. However, previous works have focused largely on Caucasian populations and less is known about Asian toddlers. We aimed to validate a semi-quantitative FFQ designed to assess dietary intakes of 18-month-old toddlers in a multi-ethnic Asian cohort.

DESIGN

An FFQ of ninety-four food items, identified based on food records of 12-month-old GUSTO children, the Southampton Women's Survey 12 Month Infancy Questionnaire and inputs from paediatric dietitians, was filled out two weeks before the 18th-month clinic visit. As the reference method, two non-consecutive 24 h recalls (24HR) were administered during and two weeks after the clinic visit. FFQ nutrient intakes were validated against averaged 24HR nutrient intakes, using the Wilcoxon signed-rank test, Spearman's rank-order correlation, cross-classification and the Bland-Altman method.

SETTING

Data from the Singapore Growing Up in Singapore Towards Healthy Outcomes (GUSTO) mother-offspring birth cohort.ParticipantsToddlers (n 188) aged 18 months.

RESULTS

Absolute nutrient intakes from the FFQ were significantly higher than from the 24HR, except for vitamin A. After energy adjustments, r range was 0·56-0·78 (macronutrients) and 0·40-0·54 (micronutrients). De-attenuation increased r to 0·58-0·96 and 0·45-0·65 for macro- and micronutrients, respectively. Of participants, ≥82·4 % (macronutrients) and ≥77·7 % (micronutrients) were classified in the same and adjacent quartiles. No clear systematic increase in intake differences with increasing mean intake was observed in Bland-Altman plots.

CONCLUSIONS

This FFQ can provide a satisfactory assessment of toddlers' energy-adjusted nutrient intakes, as well as accurately rank them in a group.

Urban-Rural Differences in Nutritional Status and Dietary Intakes of School-Aged Children in Cambodia

This study aimed to describe the nutritional status and dietary patterns of Cambodian school-aged children compared with those in the South East Asian Nutrition Survey (SEANUTS; Indonesia, Malaysia, Thailand, and Vietnam in 2011) and to clarify the urban-rural differences using data from a nationally representative sample. The survey was conducted in 2014/2015 with a sample of 2020 children aged 6–17 years from 136 randomly selected schools. Standardized anthropometric measurements and a 1-day dietary survey by 24-h recall method were conducted. Extended analyses in the present study revealed that the difference between rural and urban areas was similar to that of the SEANUTS; the overall prevalence of stunting remained high (33.2%). Stunting was more prevalent in children living in rural areas than in those in urban areas (total: 36.4% vs. 20.4%). In contrast, the overall prevalence of overweight and obesity was not as high (3.1%), but was higher among urban children in all age groups compared with those living in rural areas (total: 6.4% vs. 2.3%). Overall, the dietary intake of children did not meet the local recommended dietary allowances, which was similar to the results of the SEANUTS and differed across urban and rural areas.

Prevalence of Anaemia and Iron Deficiency among Primary Schoolchildren in Malaysia

The present study aimed to report the prevalence of anaemia and iron deficiency (ID) and to explore the associations among socio-demographic characteristics, nutritional status and inflammation status in the occurrence of anaemia and ID in a nationally representative sample of Malaysian primary schoolchildren. Using data from the South East Asian Nutrition Surveys (SEANUTS), 544 Malaysian children aged 7 to 12 years were included in this secondary analysis. Blood samples were drawn for haemoglobin and serum ferritin analysis while C-reactive protein (CRP) and α-1-acid glycoprotein (AGP) were measured to detect inflammation. Prevalence of anaemia and ID were 4.0% and 5.2%, respectively. There were significantly more anaemic indigenous bumiputra children (9.9%) than Chinese children (0.6%). Correction for inflammation did not change the prevalence of ID. More overweight/obese children than thin/normal weight children were found to have elevated acute phase protein (APP). Children with elevated inflammatory markers had significantly higher ferritin level than children without inflammation. Periodic health assessments of anaemia and ID at the population level to monitor and clarify the epidemiology of health problems are required to inform public health policies and strategies.

The Consumption of Dairy and Its Association with Nutritional Status in the South East Asian Nutrition Surveys (SEANUTS)

Despite a major decrease in undernutrition worldwide over the last 25 years, underweight and stunting in children still persist as public health issues especially in Africa and Asia. Adequate nutrition is one of the key factors for healthy growth and development of children. In this study, the associations between dairy consumption and nutritional status in the South East Asian Nutrition Survey (SEANUTS) were investigated. National representative data of 12,376 children in Indonesia, Malaysia, Thailand, and Vietnam aged between 1 and 12 years were pooled, representing nearly 88 million children in this age category. It was found that the prevalence of stunting and underweight was lower in children who consumed dairy on a daily basis (10.0% and 12.0%, respectively) compared to children who did not use dairy (21.4% and 18.0%, respectively) (p < 0.05). The prevalence of vitamin A deficiency and vitamin D insufficiency was lower in the group of dairy users (3.9% and 39.4%, respectively) compared to non-dairy consumers (7.5% and 53.8%, respectively) (p < 0.05). This study suggests that dairy as part of a daily diet plays an important role in growth and supports a healthy vitamin A and vitamin D status.

Body weight and BMI percentiles for children in the South-East Asian Nutrition Surveys (SEANUTS)

OBJECTIVE

The present study aimed to (i) calculate body-weight- and BMI-for-age percentile values for children aged 0·5-12 years participating in the South-East Asian Nutrition Survey (SEANUTS); (ii) investigate whether the pooled (i.e. including all countries) SEANUTS weight- and BMI-for-age percentile values can be used for all SEANUTS countries instead of country-specific ones; and (iii) examine whether the pooled SEANUTS percentile values differ from the WHO growth references.

DESIGN

Body weight and length/height were measured. The LMS method was used for calculating smoothened body-weight- and BMI-for-age percentile values. The standardized site effect (SSE) values were used for identifying large differences (i.e. $\left| {{\rm SSE}} \right|$ >0·5) between the pooled SEANUTS sample and the remaining pooled SEANUTS samples after excluding one single country each time, as well as with WHO growth references.

SETTING

Malaysia, Thailand, Vietnam and Indonesia.

SUBJECTS

Data from 14 202 eligible children.

RESULTS

The SSE derived from the comparisons of the percentile values between the pooled and the remaining pooled SEANUTS samples were indicative of small/acceptable (i.e. $\left| {{\rm SSE}} \right|$ ≤0·5) differences. In contrast, the comparisons of the pooled SEANUTS sample with WHO revealed large differences in certain percentiles.

CONCLUSIONS

The findings of the present study support the use of percentile values derived from the pooled SEANUTS sample for evaluating the weight status of children in each SEANUTS country. Nevertheless, large differences were observed in certain percentiles values when SEANUTS and WHO reference values were compared.

Early life secondhand smoke exposure assessed by hair nicotine biomarker may reduce children's neurodevelopment at 2years of age

Exposure to secondhand smoke (SHS) can affect fetal brain development as well as subsequent neurodevelopment. This study aimed to determine the association between prenatal and postnatal SHS exposure with children's neurodevelopment at 2years of age. Among 107 mother-child pairs from a Malaysia prospective cohort, prenatal and postnatal SHS exposure was determined based on maternal and child hair nicotine concentrations. Multiple linear regressions were used to determine the association between prenatal and postnatal levels of nicotine in maternal and children's' hair with children's neurodevelopment. After adjustment for confounders, prenatal nicotine concentration levels were negatively associated with communication (β=-2.059; p=0.015) and fine motor skills (β=-2.120; p=0.002) while postnatal nicotine concentration levels were inversely associated with fine motors (β=-0.124; p=0.004) and problem solving skills (β=-0.117; p=0.013). In conclusion, this study suggests that early life exposure to SHS may affect children's neurodevelopment.

Fruit and Vegetable Intake Patterns and Their Associations with Sociodemographic Characteristics, Anthropometric Status and Nutrient Intake Profiles among Malaysian Children Aged 1-6 Years

This study aimed to assess fruit and vegetable intake patterns and their associations with sociodemographic characteristics, anthropometric status and nutrient intake profiles among Malaysian children aged 1-6 years. Using the Malaysian dataset of South East Asian Nutrition Surveys (SEANUTS Malaysia), a total of 1307 children aged 1-6 years with complete datasets were included in this analysis. Dietary intake was assessed using age-specific, validated food frequency questionnaires. On average, Malaysian children consumed 0.91 and 1.07 servings of fruits and vegetables per day, respectively. Less than one-fifth of the children achieved the daily recommended servings of fruits (11.7%) and vegetables (15.8%). Fruit intake was associated with age, parental educational level and geographical region, and vegetable intake was associated with ethnicity and geographical region. There was little evidence of an association between fruit and vegetable intake and children's anthropometric status, but an adequate intake of fruits and vegetables contributed significantly and differently to children's micronutrient intake. Future nutrition interventions should focus on addressing the sociodemographic determinants and be tailored to the needs of the low consumers to more effectively promote and encourage the adequate intake of fruit and vegetables among young children.

Development and validation of a food frequency questionnaire for dietary intake assessment among multi-ethnic primary school-aged children

INTRODUCTION

This study aimed to develop and validate a food frequency questionnaire (FFQ) to assess habitual diets of multi-ethnic Malaysian children aged 7-12 years.

METHODS

A total of 236 primary school children participated in the development of the FFQ and 209 subjects participated in the validation study, with a subsample of 30 subjects participating in the reproducibility study. The FFQ, consisting of 94 food items from 12 food groups, was compared with a three-day dietary record (3DR) as the reference method. The reproducibility of the FFQ was assessed through repeat administration (FFQ2), seven days after the first administration (FFQ1).

RESULTS

The results of the validation study demonstrated good acceptance of the FFQ. Mean intake of macronutrients in FFQ1 and 3DR correlated well, although the FFQ intake data tended to be higher. Cross-classification of nutrient intake between the two methods showed that < 7% of subjects were grossly misclassified. Moderate correlations noted between the two methods ranged from r = 0.310 (p < 0.001) for fat to r = 0.497 (p < 0.001) for energy. The reproducibility of the FFQ, as assessed by Cronbach's alpha, ranged from 0.61 (protein) to 0.70 (energy, carbohydrates and fat). Spearman's correlations between FFQ1 and FFQ2 ranged from rho = 0.333 (p = 0.072) for protein to rho = 0.479 (p < 0.01) for fat.

CONCLUSION

These findings indicate that the FFQ is valid and reliable for measuring the average intake of energy and macronutrients in a population of multi-ethnic children aged 7-12 years in Malaysia.

Vitamin D and Calcium Intakes, Physical Activity, and Calcaneus BMC among School-Going 13-Year Old Malaysian Adolescents

Background: Dietary calcium and vitamin D are essential for bone development. Apart from diet, physical activity may potentially improve and sustain bone health. Objective: To investigate the relationship between the dietary intake of calcium and vitamin D, physical activity, and bone mineral content (BMC) in 13-year-old Malaysian adolescents. Design: Cross-sectional. Setting: Selected public secondary schools from the central and northern regions of Peninsular Malaysia. Participants: The subjects were from the Malaysian Health and Adolescents Longitudinal Research Team Cohort study (MyHeARTs). Methods: The data included seven-day diet histories, anthropometric measurements, and the BMC of calcaneal bone using a portable broadband ultrasound bone densitometer. Nutritionist Pro software was used to calculate the dietary calcium and vitamin D intakes from the diet histories, based on the Nutrient Composition of Malaysian Food Database guidance for the dietary calcium intake and the Singapore Energy and Nutrient Composition of Food Database for vitamin D intake. Results: A total of 289 adolescents (65.7% females) were recruited. The average dietary intakes of calcium and vitamin D were 377 ± 12 mg/day and 2.51 ± 0.12 µg/day, respectively, with the majority of subjects failing to meet the Recommended Nutrient Intake (RNI) of Malaysia for dietary calcium and vitamin D. All the subjects had a normal Z-score for the BMC (−2.00 or higher) with a mean of 0.55 ± 0.01. From the statistical analysis of the factors contributing to BMC, it was found that for those subjects with a higher intake of vitamin D, a higher combination of the intake of vitamin D and calcium resulted in significantly higher BMC quartiles. The regression analysis showed that the BMC might have been influenced by the vitamin D intake. Conclusions: A combination of the intake of vitamin D and calcium is positively associated with the BMC.

Assessing Body Fat of Children by Skinfold Thickness, Bioelectrical Impedance Analysis, and Dual-Energy X-Ray Absorptiometry: A Validation Study Among Malay Children Aged 7 to 11 Years

This study aims to validate skinfold (SKF) and bioelectrical impedance analysis (BIA) against dual-energy X-ray absorptiometry (DXA) in determining body fat percentage (BF%) of Malay children aged 7 to 11 years. A total of 160 children had their BF% assessed using SKF and BIA, with DXA as the criterion method. Four SKF equations (SKFBray, SKFJohnston, SKFSlaughter, and SKFGoran) and 4 BIA equations (BIAManufacturer, BIAHoutkooper, BIARush, and BIAKushner) were used to estimate BF%. Mean age, weight, and height were 9.4 ± 1.1years, 30.5 ± 9.9 kg, and 131.3 ± 8.4 cm. All equations significantly underestimated BF% (P < .05). BIA equations had reasonable agreement with DXA and were independent of BF% with BIAManufacturer being the best equation. Although BIA underestimates BF% as compared with DXA, BIA was more suitable to measure BF% in a population that is similar to this study sample than SKF, suggesting a need to develop new SKF equations that are population specific.

Anemia and Iron Deficiency in Vietnamese Children, 6 to 11 Years Old

In a population sample of 385 children, 6 to 11 years old, venous blood parameters-hemoglobin (Hb), ferritin, red blood cell count (RBC), mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), C-reactive protein (CRP), and α1-acid glycoprotein (AGP)-were determined to get insight into the iron status. The prevalence of anemia was 11.4%; 5.6% had iron deficiency (ID), whereas 0.4% had ID anemia. Correction for inflammation based on CRP and AGP did not markedly change the overall prevalence of ID and ID anemia. Stunted children had lower Hb and ferritin values compared with nonstunted children, and thin children had lower values compared with normal-weight or overweight and obese children. Many nonanemic children had alert values for RBC, MCV, MCH, and MCHC. It is concluded that although the prevalence of anemia is of the magnitude of a mild public health problem, the iron status of many nonanemic children is borderline, as indicated by a high number of children with low values for red blood cytology.

Physical Activity Pattern of Malaysian Preschoolers: Environment, Barriers, and Motivators for Active Play

Children's physical activity has been correlated with child characteristics and social or physical environment. This study aimed to compare preschoolers' physical activity among various sociodemographic characteristics and to determine barriers, motivators, and environmental factors for active play. A total of 835 preschoolers were included in this analysis. Time spent on active play, quiet play, and screen time was reported by parents. Boys spent significantly more time on active play and screen time than girls. Time spent on quiet play was highest in East Coast Peninsular Malaysia and lowest in Sarawak. Some 40% of children achieved active play recommendation while 27% exceeded daily screen time recommendation. Most parents reported that their child played actively in the house area; and that the main barrier and motivator to active play were safety and child's enjoyment, respectively. These findings demonstrate that sociodemographic characteristics and environment should be considered in designing physical activity intervention programs.

Nutrient Intake in Vietnamese Preschool and School-Aged Children is Not Adequate: The Role of Dairy

BACKGROUND

The traditional Vietnamese diet carries the risk of micronutrient deficiencies, and a substantial part of children <11 years do not meet the Vietnamese recommended dietary allowance (RDA) for a range of nutrients. Dairy products are known for their high nutrient density and milk in particular for its provision of high-quality protein and relevant concentrations of calcium, magnesium, vitamin B2, vitamin B12, and pantothenic acid.

OBJECTIVE

The present study aimed to evaluate the contribution of dairy to the overall nutrient intakes in the diets of Vietnamese children and to gain insight into factors affecting dairy consumption.

METHODS

Food intake, including dairy, was assessed by a 24-hour recall in 2811 Vietnamese children clustered into 4 age-groups: 1.0 to 2.9, 3.0 to 5.9, 6.0 to 8.9, and 9.0 to 11.9 years, and dairy was categorized into 6 product groups based on available information in the Vietnamese food composition table.

RESULTS

Higher dairy intake was associated with significantly higher intakes (in % estimated average requirement and %RDA) of all assessed nutrients, and largest effects and strongest associations were found for vitamin B2, calcium, vitamin D, fat, vitamin B1, protein, vitamin A, and zinc. Age, area of residence, and wealth status influenced the consumption of dairy products. Furthermore, age also influenced nutrient intake adequacy, which was generally lower at older age, especially after the age of 6 years.

CONCLUSION

The nutrient composition of the diet in especially Vietnamese school-aged children requires attention, and (fortified) dairy can play an important role in this.

Differences in Body Build in Children of Different Ethnic Groups and their Impact on the Prevalence of Stunting, Thinness, Overweight, and Obesity

BACKGROUND

The prevalence of stunting, thinness, overweight, and obesity among children differs by ethnicity. It is not known whether differences in body build across the ethnic groups influence the interpretation of nutritional parameters.

OBJECTIVE

To explore the differences in body build across the 5 main ethnic groups in Malaysia and to determine whether differences in body build have an impact on the interpretation of nutrition indicators.

METHODS

A total of 3227 children aged 2.0 to 12.9 years who participated in the South East Asian Nutrition Surveys (SEANUTS) in Malaysia were included in this analysis. Body weight, height, sitting height, wrist and knee breadths, and biceps and subscapular skinfolds were measured, and relative leg length, slenderness index, and sum of skinfolds were calculated. Z scores for height-for-age (HAZ) and body mass index-for-age (BAZ) were calculated using the World Health Organization (WHO) 2007 growth standards.

RESULTS

Differences in relative leg length and slenderness across the ethnic groups were correlated with HAZ and BAZ. Correction for differences in body build did, in some ethnic groups, have significant impact on the prevalence of stunting, thinness, overweight, and obesity, and the pattern of prevalence across ethnic groups changed.

CONCLUSION

At the population level, corrections for body build had only minor and mostly nonsignificant effects on prevalence, but at an individual level, corrections for body build placed a substantial number of children in different height or weight categories. Whether these misclassifications warrant additional assessment of body build in clinical practice will need further investigation.

Length and height percentiles for children in the South-East Asian Nutrition Surveys (SEANUTS)

OBJECTIVE

Health and nutritional information for many countries in the South-East Asian region is either lacking or no longer up to date. The present study aimed to calculate length/height percentile values for the South-East Asian Nutrition Survey (SEANUTS) populations aged 0·5-12 years, examine the appropriateness of pooling SEANUTS data for calculating common length/height percentile values for all SEANUTS countries and whether these values differ from the WHO growth references.

DESIGN

Data on length/height-for-age percentile values were collected. The LMS method was used for calculating smoothened percentile values. Standardized site effects (SSE) were used for identifying large or unacceptable differences (i.e. $\mid\! \rm SSE \!\mid$ >0·5) between the pooled SEANUTS sample (including all countries) and the remaining pooled SEANUTS samples (including three countries) after weighting sample sizes and excluding one single country each time, as well as with WHO growth references.

SETTING

Malaysia, Thailand, Vietnam and Indonesia.

SUBJECTS

Data from 14202 eligible children were used.

RESULTS

From pair-wise comparisons of percentile values between the pooled SEANUTS sample and the remaining pooled SEANUTS samples, the vast majority of differences were acceptable (i.e. $\mid\! \rm SSE \!\mid$ ≤0·5). In contrast, pair-wise comparisons of percentile values between the pooled SEANUTS sample and WHO revealed large differences.

CONCLUSIONS

The current study calculated length/height percentile values for South East Asian children aged 0·5-12 years and supported the appropriateness of using pooled SEANUTS length/height percentile values for assessing children's growth instead of country-specific ones. Pooled SEANUTS percentile values were found to differ from the WHO growth references and therefore this should be kept in mind when using WHO growth curves to assess length/height in these populations.

Transition of maternal and child nutrition in Asia: implications for public health

PURPOSE OF REVIEW

This article reviews the maternal and child nutrition situation in Asia in transition and its public health implications.

RECENT FINDINGS

Countries in Asia are facing a double burden of malnutrition. Accessibility to high energy, less nutrient-dense foods or processed foods affects current dietary patterns, whereas industrialization is leading to more sedentary lifestyles both in rural and urban areas. Stunting and wasting among young children persist but have declined in severity, whereas overweight and obesity have risen rapidly. Growth faltering in height during the first 2 years of life has affected muscle mass accretion, but rapid weight gain after 2 years of age has led to more fat accretion, imposing risks of childhood obesity and consequent metabolic disorders. The number of women entering pregnancy with low BMI has decreased, but increasing BMI is noticeable. Prepregnancy BMI and gestational weight gain are important determinants of maternal nutrition during pregnancy, the risk of gestational diabetes and postpartum weight retention, as well as obesity and diet-related noncommunicable diseases in later adulthood.

SUMMARY

Asia in transition is faced with persistent undernutrition and increasing trends of obesity and metabolic disorders among children and women. The first 1000 days from conception is a critical period, but it is also a window of opportunity for preventing double burden of malnutrition in Asian countries characterized by a nutrition transition.

Radial quantitative ultrasound and dual energy x-ray absorptiometry: intermethod agreement for bone status assessment in children

Aim. To validate a radial quantitative ultrasound (QUS) system with dual energy X-ray absorptiometry (DXA), a criterion technique in bone status assessment among children. Methods. Bone health was evaluated using a radial QUS system (Sunlight Omnisense 8000P) to measure the speed of sound (SOS) at one-third distal radius of the nondominant hand and DXA (Hologic QDR) was used to assess whole body bone mineral density (BMD). Results. Some 29.9% of the children were grossly misclassified according to quartiles of BMD and radial SOS. Poor agreement was observed between Z-scores of radial SOS and whole-body BMD (mean difference = 0.6 ± 0.9; 95% limits of agreement = −1.4 to 2.6). With a cut-off value of −1.0, radial SOS yielded satisfactory sensitivity (80%) and specificity (93%) for the detection of children with low BMD. Conclusion. The observed poor agreement in the present study suggests that radial QUS and DXA are not comparable and hence are not interchangeable in evaluating bone status of the children.

Daily physical activity and screen time, but not other sedentary activities, are associated with measures of obesity during childhood

Childhood obesity is related to low physical activity level and a sedentary lifestyle. The aim of this study was to assess the physical activity level and sedentary behaviour of Malaysian children aged 7 to 12 years and to examine their association with body mass index (BMI), BMI-for-age Z-score (BAZ), body fatness (%BF) and waist circumference (WC). A total of 1736 children, representing all ethnic groups were recruited from six regions of Malaysia. Anthropometric measurements included body weight, height and waist circumference. Body fat percentage (%BF) was assessed using bioelectrical impedance. Physical activity was assessed by a physical activity questionnaire (PAQ) in all children and by pedometers in a subsample (n = 514). PAQ score and pedometer step counts were negatively associated with BMI, BAZ, %BF and WC after adjusting for covariates. Screen time was positively associated with BAZ and WC. However, other sedentary activities were not significantly related with any anthropometric indicators. Strategies to promote active living among children in Malaysia should focus not only on increasing physical activity but also emphasise reduction in sedentary behaviours.

Iodine nutritional status after the implementation of the new iodized salt concentration standard in Zhejiang Province, China

Background

Iodine deficiencies were prevalent in China until the introduction of universal salt iodization (USI) in 1995. In 2012, the standard salt iodine concentration was adjusted to 20-30 mg/kg. The success of USI for the control of iodine deficiency disorders requires monitoring its effect at a population level.

Methods

Two cross sectional surveys of a representative sample of children aged 8–10 years in Zhejiang Province were carried out in 2011 and 2013. Data on participants’ socio-demographic characteristics were collected from the children using a structured questionnaire. Spot urine samples were collected and delivered to local Center for Disease Control and Prevention laboratory for measuring urinary iodine concentration. In 2011, out of 420 selected children aged 8–10 years, 391 were recorded and provided urine samples. In 2013, out of 1560 selected children aged 8–10 years, 1556 were recorded and provided urine samples.

Results

The median urinary iodine concentration of subjects in the 2013 survey was 174.3 μg/L, significantly lower than that of 2011(p = 0.000). The median urinary iodine concentration of subjects living in urban and rural areas in the 2013 survey was 169.0 μg/L, and 186.1 μg/L respectively, significantly lower than that of 2011 only for subjects living in urban areas (p = 0.000). There were no significant differences for subjects living in rural areas in the survey in 2011 and in 2013 (p = 0.086).

Conclusions

At the time the new local iodization policy put forward, iodine nutrition was generally adequate in both urban and rural areas, suggesting that the new policy for adjusting the standard salt iodine concentration is effective. Our data also indicate that the reason people living in urban areas had a lower urinary iodine concentration than people in rural areas may be due to their preference for using non-iodized salt in the last 2 or 3 years. Maintaining USI at an appropriate level is an important part of preventing iodine deficiency disorders and should always be based on regular monitoring and comparison of urinary iodine concentration by province.

Nutritional challenges for children in societies in transition

PURPOSE OF REVIEW

This review is to explore the childhood nutrition and health in relation to socioeconomic changes in transitional countries, and to describe the good experiences and policies in these countries to combat childhood nutritional challenges.

RECENT FINDINGS

Double burden of malnutrition - the coexistence of under-nutrition and over-nutrition in the same population - is a prominent public health concern in transitional countries. With rapid industrialization, these countries are facing a growing epidemic of overweight/obesity in children and adolescents. The increasing prevalence of childhood overweight/obesity is a likely consequence of behavioral changes, and accompanied with an increasing incidence of noncommunicable chronic diseases. Although remarkable improvement of childhood nutrition was achieved, the stunting growth and micronutrient deficiency remain to be child health issues in transitional countries.

SUMMARY

The social transition caused a broad range of nutrition-associated problems. Previous successful experiences indicated that if appropriate action is undertaken, the child nutritional problems accompanied with economic transition could be controlled to some extent. However, greater efforts are needed to improve the status of childhood nutrition in transitional countries.

Food consumption and nutritional and biochemical status of 0·5-12-year-old Indonesian children: the SEANUTS study

Indonesia is currently facing the double burden of malnutrition. While undernutrition is still a major public health problem, the prevalence of overnutrition is increasing. The objective of the South East Asian Nutrition Survey (SEANUTS) was to provide up-to-date data on nutritional status, food consumption and biochemical parameters related to nutrition for children aged 0·5-12 years. The SEANUTS study in Indonesia was conducted in a nationwide representative sample of 7·211 children using multistage cluster sampling based on probability proportional to size, stratified for geographical location, in forty-eight out of 440 districts/cities. The results show that the growth (weight for age, height for age, weight for height and BMI for age) of Indonesian pre-school- and school-aged children is below the WHO standards. The older the children, the more the deviation from the WHO standard curves. Underweight was more prevalent in rural areas (28·9 v. 19·2%) and overweight/obesity was observed to be more widespread in urban areas (5·6 v. 3·2%). The prevalence varied with age groups and sexes. The overall prevalence of stunting was 25·2 and 39·2% in urban and rural areas, respectively. The prevalence of anaemia was nearly 55% in children aged 0·5-1·9 years and ranged from 10·6 to 15·5% in children aged 2-12 years. Fe deficiency was observed in 4·1-8·8% of the children. The percentage of children with dietary intakes of energy, protein, and vitamins A and C below the Indonesian RDA was high and differed across urban and rural areas and age groups.

Double burden of undernutrition and overnutrition in Vietnam in 2011: results of the SEANUTS study in 0·5-11-year-old children

The Vietnamese South East Asian Nutrition Survey (SEANUTS), a cross-sectional study, was undertaken to assess the nutritional status in a nationally representative sample of children aged 0·5-11·9 years. A multi-stage cluster-randomised sampling method was used to recruit 2872 children. Anthropometric measurements included weight, height, mid-upper arm circumference, and waist and hip circumferences. Blood biochemistry involved analyses of Hb, serum ferritin, and vitamins A and D. Dietary intake was assessed using a 24 h recall questionnaire, and nutrient intakes were compared with the Vietnamese RDA. In children aged < 5 years, approximately 14% were stunted, 8·6% underweight and 4·4% thin. A higher prevalence of stunting (15·6%) and underweight (22·2%) was observed in school-aged children. Undernutrition was more prevalent in rural areas than in urban areas. In contrast, almost 29% of the urban children were either overweight or obese when compared with 4% of the overweight children and 1·6% of the obese children in rural areas. A higher percentage of children in the age group 0·5-1·9 years and residing in rural areas had low Hb levels than those in the age group 2·0-5·9 years and residing in urban areas. In children aged 6-11 years, a small percentage had low Hb (11-14%) and vitamin A (5-10%) levels, but almost half the children (48-53%) had vitamin D insufficiency. Food consumption data indicated that the children did not meet the RDA for energy, protein, Fe, vitamin A, vitamin B1 and vitamin C. Results from the SEANUTS highlight the double burden of malnutrition in Vietnam. Information from the SEANUTS can serve as an input for targeted policy development, planning and development of nutrition programmes.

Relationship between anthropometric indicators and cognitive performance in Southeast Asian school-aged children

Nutrition is an important factor in mental development and, as a consequence, in cognitive performance. Malnutrition is reflected in children's weight, height and BMI curves. The present cross-sectional study aimed to evaluate the association between anthropometric indices and cognitive performance in 6746 school-aged children (aged 6–12 years) of four Southeast Asian countries: Indonesia; Malaysia; Thailand; Vietnam. Cognitive performance (non-verbal intelligence quotient (IQ)) was measured using Raven's Progressive Matrices test or Test of Non-Verbal Intelligence, third edition (TONI-3). Height-for-age z-scores (HAZ), weight-for-age z-scores (WAZ) and BMI-for-age z-scores (BAZ) were used as anthropometric nutritional status indices. Data were weighted using age, sex and urban/rural weight factors to resemble the total primary school-aged population per country. Overall, 21 % of the children in the four countries were underweight and 19 % were stunted. Children with low WAZ were 3·5 times more likely to have a non-verbal IQ < 89 (OR 3·53 and 95 % CI 3·52, 3·54). The chance of having a non-verbal IQ < 89 was also doubled with low BAZ and HAZ. In contrast, except for severe obesity, the relationship between high BAZ and IQ was less clear and differed per country. The odds of having non-verbal IQ levels < 89 also increased with severe obesity. In conclusion, undernourishment and non-verbal IQ are significantly associated in 6–12-year-old children. Effective strategies to improve nutrition in preschoolers and school-aged children can have a pronounced effect on cognition and, in the longer term, help in positively contributing to individual and national development.