SEANUTS: the nutritional status and dietary intakes of 0.5–12-year-old Thai children

Association between anaemia and vitamin D insufficiency among 6- to 12-month-old infants: implications for clinical practice

BACKGROUND

Anaemia and vitamin D insufficiency (VDI) are among the most common nutritional problems. Anaemia screening is routinely performed; however, screening for VDI is not usually recommended.

OBJECTIVES

To study the association between anaemia and VDI and identify the risk factors for VDI.

METHODS

We conducted a cross-sectional study of 120 infants aged 6-12 months attending a well-child clinic at Songklanagarind Hospital between December 2020 and November 2021. Sociodemographic data and 24-h food records were also collected. Blood samples were obtained for complete blood count and 25-hydroxyvitamin D [25(OH)D] levels. Logistic regression analysis was used to determine risk factors for VDI.

RESULTS

The mean 25(OH)D level was 22.2 ± 8.9 ng/mL in anaemic infants and 27.2 ± 9.6 ng/mL in non-anaemic infants (P value 0.01). The median (IQR) Hb level was 11.1 g/dL (10.3, 11.4) in the VDI group and 11.4 g/dL (11, 12.1) in the non-VDI group (P value 0.002). The proportion of breastfed infants was higher in infants with anaemia (80%) (P < 0.001) and VDI (85.3%) (P < 0.001). Sunlight exposure <15 min/day (odds ratio [OR] 3.84; 95% confidence interval [CI]: 1.23-12.00; P = 0.020) was a risk factor, and vitamin D intake (OR 0.37; 95% CI: 0.20-0.74; P = 0.004) was a protective factor for VDI.

CONCLUSION

Infants with anaemia, short duration of sunlight exposure, breastfeeding, low vitamin D intake, and low iron intake were more likely to be vitamin D insufficient. However, after adjustment in the multivariate analyses, only sunlight exposure and vitamin D intake were significantly associated with vitamin D insufficiency.

Vitamin D Deficiency in Childhood Cancer Survivors: Results from Southern Thailand

There is limited information on vitamin D deficiency among childhood cancer survivors (CSS), especially in tropical countries. The aims of this study are to determine the prevalence and risk factors for vitamin D deficiency in CCSs. This study was conducted at the long-term follow-up clinic for CCSs at Prince of Songkla University, Songkhla, Thailand. All CCSs who were followed up between January 2021 and March 2022 were enrolled. Demographic data, dietary dairy intake, average weekly duration of outdoor activities, total 25-hydroxyvitamin D [25(OH)D] levels, parathyroid hormone levels, and blood chemistry were collected. A total of 206 CCSs with a mean age at follow-up of 10.8 ± 4.7 years were included. The prevalence of vitamin D deficiency was 35.9%. Female gender (odds ratio (OR): 2.11, 95% CI: 1.08-4.13), obesity (OR: 2.01, 95% CI: 1.00-4.04), lack of outdoor activities (OR: 4.14, 95% CI: 2.08-8.21), and lower dietary dairy intake (OR: 0.59, 95% CI: 0.44-0.80) were independent risk factors for vitamin D deficiency. Vitamin D deficiency was common in CCSs and associated with female gender, obesity, lack of outdoor activities, and lower dietary dairy intake. Regular 25(OH)D screening should be established in long-term care to identify those who require vitamin D supplements.

Prolonged Egg Supplement Advances Growing Child's Growth and Gut Microbiota

Protein-energy malnutrition still impacts children's growth and development. We investigated the prolonged effects of egg supplementation on growth and microbiota in primary school children. For this study, 8-14-year-old students (51.5% F) in six rural schools in Thailand were randomly assigned into three groups: (1) whole egg (WE), consuming 10 additional eggs/week (n = 238) (n = 238); (2) protein substitute (PS), consuming yolk-free egg substitutes equivalent to 10 eggs/week (n = 200); and (3) control group (C, (n = 197)). The outcomes were measured at week 0, 14, and 35. At the baseline, 17% of the students were underweight, 18% were stunted, and 13% were wasted. At week 35, compared to the C group the weight and height difference increased significantly in the WE group (3.6 ± 23.5 kg, p < 0.001; 5.1 ± 23.2 cm, p < 0.001). No significant differences in weight or height were observed between the PS and C groups. Significant decreases in atherogenic lipoproteins were observed in the WE, but not in PS group. HDL-cholesterol tended to increase in the WE group (0.02 ± 0.59 mmol/L, ns). The bacterial diversity was similar among the groups. The relative abundance of Bifidobacterium increased by 1.28-fold in the WE group compared to the baseline and differential abundance analysis which indicated that Lachnospira increased and Varibaculum decreased significantly. In conclusion, prolonged whole egg supplementation is an effective intervention to improve growth, nutritional biomarkers, and gut microbiota with unaltered adverse effects on blood lipoproteins.

Prevalence and risk factors for vitamin D insufficiency in 6-12-month-old infants: a cross-sectional study in Southern Thailand

BACKGROUND

Vitamin D is an essential micronutrient for bone mineralization and bone growth in children. There have been few studies to date of vitamin D status in infants aged 6-12 months in Southeast Asian countries.

AIM

To examine the prevalence of vitamin D insufficiency (VDI, including vitamin D deficiency) in healthy infants and the risk factors for VDI in southern Thailand.

METHODS

A cross-sectional study was carried out in 120 healthy infants aged 6-12 months and their mothers. Blood samples were obtained for measurement of serum calcium, phosphate, alkaline phosphatase, albumin, parathyroid hormone and 25-hydroxyvitamin D (25OHD) levels. The mothers were interviewed for their infants feeding intake, sunlight exposure, type of dress, and sunscreen use. Chi-square and t-test were used to compare between groups for categorical and continuous variables, respectively. Pearson correlation was used to identify the relationship between serum levels of 25OHD of the infants and other biochemical variables of the infants and serum levels of maternal 25OHD. Logistic regression analysis was used to identify the factors associated with vitamin D status.

RESULTS

The prevalence of VDI in our study infants was high at 28.3%, all of whom were mainly breastfed infants. Subgroup analysis of the mainly breastfed infants found that the risk factors for VDI were maternal VDI and a short duration of sunlight exposure. The serum 25OHD levels of the mainly breastfed infants were significantly positively correlated with the maternal serum 25OHD levels (r = 0.49, p-value < 0.01) and with sunlight exposure duration (r = 0.40, p-value < 0.01).

CONCLUSIONS

The prevalence of VDI was high in 6-12-month-old infants, particularly those who were mainly breastfed from VDI mothers, and who had short durations of sunlight exposure. As breast milk contains adequate amounts of most important vitamins and growth factors, breastfeeding is still encouraged for infants with 400 IU vitamin D daily supplementation to prevent VDI.

Comparison between School-Age Children with and without Obesity in Nutritional and Inflammation Biomarkers

Childhood obesity is a major health problem. We examined differences between children with obesity and normal weight in nutritional and inflammation biomarkers. A cross-sectional study was conducted among healthy children aged 10-12 years from Arab villages in Israel. Parents were interviewed regarding sociodemographic and children's health status. Body weight and height measurements were performed and weight categories were defined using the 2007 WHO growth curves. Blood samples were tested for complete blood count, levels of iron, ferritin, lipids, uric acid, and C-reactive protein (CRP). Overall, 146 children (59.0% males, mean age = 11.3 [SD = 0.5]) were enrolled. In total 43.8%, 14.1% and 42.3% of the participants had normal weight, overweight and obesity, respectively. A multivariable logistic regression model showed that children with overweight and obesity had lower iron, and HDL-C levels than children with normal weight. Levels of CRP, uric acid, LDL-C and lymphocytes were higher among children with overweight and obesity. In conclusion, our findings highlight the worse metabolic and nutritional status in overweight and obese children. Such markers play a role in metabolic syndrome, thus suggesting that metabolic syndrome might start in childhood.

Dietary diversity and micronutrient adequacy among women of reproductive age: a cross-sectional study in Southern Thailand

Introduction

Adequate nutritional intake of both macronutrients and micronutrients is essential for maintaining good health throughout life, particularly for women of reproductive age (WRA). The Minimum Dietary Diversity for WRA (MDD-W), or the sum of dietary diversity, is recommended as a simple indicator to identify at-risk WRA populations. However, there are no studies on the MDD-W among WRA in Thailand.

Objectives

To determine food group diversity, MDD-W, and micronutrient intake of WRA in Southern Thailand.

Participants

From December 2020 to November 2021, 120 healthy, young WRA (average age 33.2 ± 4.5 years) were enrolled.

Methods

A 24-h food record was used to quantitatively and qualitatively assess the food consumed. Dietary diversity was classified into ten food groups. The macronutrients and 15 micronutrients were calculated using the software program INMUCAL, which is the standard program for calculating nutrients in Thai food. The calculated intake of each micronutrient was transformed to the probability of adequacy (PA).

Results

The most common foods consumed were rice, followed by meat, eggs, fruits, and vegetables. Fewer than 40% of the participants consumed beans, dairy products, vitamin A-rich fruits and vegetables, dark green vegetables, and pulses. The average MDD-W score was 5 (range 2–8). The mean caloric intake (1,865 cal/day) was adequate for non-lactating WRA but was approximately 300 kcal/day lower than the recommendation for lactating WRA. Most WRA consumed lower amounts of micronutrients than those recommended. The mean PA (MPA) of the 15 micronutrients was 0.33 (range 0.0–0.9).

Conclusions

Non-pregnant WRA in Songkhla consumed adequate macronutrients but inadequate micronutrients. A nutritional education program regarding the importance of micronutrients should be provided to the public, with special attention to WRA.

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).

Quantity and Source of Protein during Complementary Feeding and Infant Growth: Evidence from a Population Facing Double Burden of Malnutrition

BACKGROUND

While high protein intake during infancy may increase obesity risk, low qualities and quantities of protein contribute to undernutrition. This study aimed to investigate the impact of the amount and source of protein on infant growth during complementary feeding (CF) in a country where under- and overnutrition co-exist as the so-called the double burden of malnutrition.

METHODS

A multicenter, prospective cohort was conducted. Healthy term infants were enrolled with dietary and anthropometric assessments at 6, 9 and 12 months (M). Blood samples were collected at 12M for IGF-1, IGFBP-3 and insulin analyses.

RESULTS

A total of 145 infants were enrolled (49.7% female). Animal source foods (ASFs) were the main protein source and showed a positive, dose-response relationship with weight-for-age, weight-for-length and BMI z-scores after adjusting for potential confounders. However, dairy protein had a greater impact on those parameters than non-dairy ASFs, while plant-based protein had no effect. These findings were supported by higher levels of IGF-1, IGFBP-3 and insulin following a higher intake of dairy protein. None of the protein sources were associated with linear growth.

CONCLUSIONS

This study showed the distinctive impact of different protein sources during CF on infant growth. A high intake of dairy protein, mainly from infant formula, had a greater impact on weight gain and growth-related hormones.

Global Trends in the Availability of Dietary Data in Low and Middle-Income Countries

Individual-level quantitative dietary data can provide suitably disaggregated information to identify the needs of all population sub-groups, which can in turn inform agricultural, nutrition, food safety, and environmental policies and programs. The purpose of this discussion paper is to provide an overview of dietary surveys conducted in low- and middle-income countries (LMICs) from 1980 to 2019, analyzing their key characteristics to understand the trends in dietary data collection across time. The present study analyzes the information gathered by the Food and Agriculture Organization of the United Nations/World Health Organization Global Individual Food consumption data Tool (FAO/WHO GIFT). FAO/WHO GIFT is a growing repository of individual-level dietary data and contains information about dietary surveys from around the world, collected through published survey results, literature reviews, and direct contact with data owners. The analysis indicates an important increase in the number of dietary surveys conducted in LMICs in the past four decades and a notable increase in the number of national dietary surveys. It is hoped that this trend continues, together with associated efforts to validate and standardize the dietary methods used. The regular implementation of dietary surveys in LMICs is key to support evidence-based policies for improved nutrition.

Nutritional quality of lunch meals and plate waste in school lunch programme in Southern Thailand

Food waste globally affects food security and sustainability. There currently are few studies focusing on food waste in schools. The present study aimed to determine the meal quality and plate waste in school lunch programme in Thailand. This cross-sectional study was conducted in canteens of representing kindergarten and elementary schools in Southern Thailand within their real-life context. The assessment was carried out over five consecutive school days in July–August 2020 for each school, at which two types of menus, including rice with side dish and one-dish meal were served. Waste collection and quantification were conducted by selective aggregate weighing, according to the Food Loss and Waste Protocol. All lunch menus contained excess rice but insufficient meats, fruits, vegetables and eggs, regarding the national lunch standard. For each serving portion, 7–33 % rice, 9–22 % meats, 7–65 % vegetables, 1–19 % fruits and 3–14 % eggs were discarded. Plate waste from rice with side dish menus (10–29 %) was more than one-dish meals (7–17 %). By estimation, each kindergartener generated 71⋅4 g plate waste daily, accounting for the caloric and monetary values of 146 kcal and 0⋅16 US dollar. The amount of plate waste and the respective caloric and monetary losses were less obvious at the elementary school. Plate waste affected the adequacy of food intakes of schoolchildren from lunch meals. The data obtained from the present study will be useful for planning and implementation of school lunch programme in Thailand and countries with similar context.

Mathematical modeling to inform the development of national guidelines on infant feeding in Thailand

The development of national dietary guidelines promoting healthy food choices is a public health priority in Thailand. In developing the recent national complementary feeding guidelines (CFGs) for 6- to 12-month-old children, mathematical modeling was used to inform decisions. Model parameters were derived from nationally representative dietary data and analyzed for 11 micronutrients by age group, using linear programming analysis in Optifood. Models were run to identify micronutrients whose nutrient reference values could not be met using local foods as consumed (problem nutrients), evaluate the original 2012 Thai CFGs, and predict the nutritional benefits of a specific fortified complementary food. The results identified three problem nutrients (iron, calcium, and zinc), which, for 9- to 11-month-olds, were reduced to one when the fortified food was modeled. The number of servings/week of vegetables and meat, fish or eggs were higher, and of oil and fruit were lower, in the modeled nutritionally best rather than observed diets (medians). When modeled, the original Thai CFGs were not feasible because the energy constraint was exceeded; hence, in revising them, the recommended number of servings/week of oil and fruit were reduced. This study demonstrates the advantages of using mathematical modeling, when revising national CFGs, to evaluate and improve them.

Scurvy in children - A neglected disease?

BACKGROUND

The incidences of pediatric scurvy has decreased substantially, particularly in developed countries, but there are still reports of it from developing countries. Unusual manifestations have led to delays in diagnosis and treatment. Nevertheless, there are few publications regarding misdiagnosis of scurvy. The objective is to determine dietary factors, clinical manifestations, laboratory and radiologic findings, treatment, and outcomes of scurvy cases. The occurrence of misdiagnosis and its associated factors are also explored.

METHOD

The medical records of 0-18 year-old children from 2003 to 2016, diagnosed with scurvy, were included and reviewed. Clinical data, and data regarding feeding history, nutritional status, laboratory and radiologic findings, and misdiagnosis were collected. Univariate and logistic regression analysis were used for identification of the independent associated factors.

RESULTS

The study consisted of 106 children. The boys-to-girls ratio was 2.2:1, and their mean age was 44.65 months ± 30.50 months. The common manifestations were refusal to walk, tenderness, and swelling at the lower extremities. Four participants had unusual manifestations including proptosis and scalp hematoma. Low serum vitamin C level and abnormal radiologic findings were detected in most patients. All of them fully recovered after receiving vitamin C supplementation. Misdiagnosis was identified in 74 cases (69%). Logistic regression analysis revealed that temperature higher than or equal to 38 °C, participants aged 3 years or below, and swelling at lower extremities were independently associated with misdiagnosis (adjusted OR 5.91, 3.78, and 3.56 respectively).

CONCLUSIONS

Scurvy still exists, and misdiagnosis often occurs. Taking a careful medical history and conducting a physical examination are still the best way to diagnose scurvy.

Association of Infant Feeding Practices with Iron Status and Hematologic Parameters in 6-Month-Old Infants

Background: Infants’ feeding practices in the first 6 months of life and their association with iron status and hematologic parameters has not been well studied. We aim to evaluate this association. Methods: In a retrospective chart review, we identified 403 infants who received laboratory screening for anemia at 6-month visits. Infants were categorized into four groups according to feeding practices. Hematologic parameters and incidence of anemia, iron deficiency (ID), and iron deficiency anemia (IDA) were compared. Results: In total, 105 infants were breastfed (BF), 78 were breastfed with iron supplementation starting at 4 months (BI), 109 were mixed-fed (breast milk and formula) with or without iron supplementation (MF), and 111 were formula-fed (FF). The BF group had the highest incidence of anemia (38.1%), ID (28.6%), and IDA (17.1%) when compared with the other groups (p < 0.001). In multivariate logistic regression, BI, MF, and FF infants had 90.4%, 97.5%, and 96.9% decreased risk of IDA, respectively, with BF infants as a reference group. Conclusion: The incidence of anemia, ID, and IDA at age 6 months was higher in BF than FF or MF infants. However, iron supplements in BF infants starting at 4 months significantly reduced their ID and IDA incidence.

Association of Iron-Deficiency Anemia and Non-Iron-Deficiency Anemia with Neurobehavioral Development in Children Aged 6-24 Months

(1) Background: Anemia has comprehensive adverse effects on the growth and development of children. In this study, we analyzed the potential effects of different types of anemia on early-life neurobehavioral development. (2) Methods: A total of 2601 children aged 6-24 months, whose parents agreed to participate in this study, underwent routine blood tests and neurobehavioral development assessment. The children's parents or other primary caregivers were interviewed with a face-to-face questionnaire at the time of enrollment in the study. Anemia was determined by hemoglobin < 110 g/L and classified into iron-deficiency and non-iron-deficiency anemia according to the levels of serum ferritin, C-reactive protein, and alpha-1-acid glycoprotein. Neurobehavioral development was assessed by the China Developmental Scale for Children and divided into five domains: gross motor, fine movement, adaptability, language, and social behavior. The development quotient (DQ) was used to measure the level of total neurobehavioral development and each domain of neurobehavioral development. (3) Results: The prevalence of anemia in children aged 6-24 months was 26.45%, of which iron-deficiency anemia only accounted for 27.33%. Compared with children without anemia, those with iron-deficiency anemia had a significantly lower developmental quotient (DQ) for total neurobehavioral development and gross motor and adaptability development. The partial regression coefficients were -1.33 (95% CI -2.36, -0.29; p = 0.012), -1.88 (95% CI -3.74, -0.03; p = 0.047), and 1.48 (95% CI -2.92, -0.05; p = 0.042), respectively. Children with non-iron-deficiency anemia had significantly lower DQ for total neurobehavioral development and gross motor and fine movement development than those without anemia. The partial regression coefficients were -0.94 (95% CI -1.64, -0.25; p = 0.008), -1.25 (95% CI -2.48, -0.03; p = 0.044), and -1.18 (95% CI -2.15, -0.21; p = 0.017), respectively. There were no statistically significant differences in total neurobehavioral development and the five domains of neurobehavioral development between children with non-iron-deficiency and iron-deficiency anemia. The partial β values were 0.40 (95% CI -1.53, 2.33; p = 0.684), 0.21 (95% CI -1.39, 1.81; p = 0.795), 0.63 (95% CI -1.03, 2.28; p = 0.457), 0.16 (95% CI -1.78, 2.10; p = 0.871), 0.35 (95% CI -1.32, 2.01; p = 0.684), and 0.34 (95% CI -0.77, 1.46; p = 0.545), respectively. (4) Conclusions: Both iron-deficiency anemia and non-iron-deficiency anemia were negatively correlated with the neurobehavioral development of children. Negative correlations were found between iron-deficiency anemia and gross motor and adaptability development and between non-iron-deficiency anemia and gross motor and fine movement development.

Consumption of Calcium and Knowledge About Calcium Sources and Nutrition Labels Among Lower Secondary School Students in Thailand

Objective

A three study research program was conducted to identify high calcium products available in the market (study I), identify high calcium products that were known or consumed by lower secondary school students in the last three months (study II), and identify the amount and sources of calcium that students had consumed in the prior 24 hours, their knowledge about sources of high calcium and how to interpret calcium information on nutrition labels of food packages (study III).

Methods

In study I, a cross-sectional market survey was employed. In studies II and III, a school-based cross-sectional survey was employed. The survey population was students enrolled in grades 7–9 (11–14 years old) in a medium-sized lower secondary school in semi-urban Khon Kaen, Thailand. A total of 309 students were invited, with 168 and 209 students participating in studies II and III, respectively. Data were collected with self-administered questionnaires.

Results

Ninety-three high calcium products were identified. Only 49 were known or consumed by students in the last three months. The median amount of calcium consumed in the previous 24 hours was 410 mg (IQR: 160, 983). Only 31.1% of students (65/209) consumed more than the Thai recommended daily intake (TRDI) of calcium (800mg) in the previous 24 hours. Their main source of calcium was milk. Other high calcium items that were consumed were malt drink, minnow, canned fish, calcium fortified soy milk and Chinese kale. The overall average knowledge score was 6.5±2.4 out of a maximum of 17. The average knowledge scores for high calcium food sources and for interpreting the calcium information on a sample nutrition label were 4.6+1.8 (out of 12), and 1.9±1.2 (out of 5), respectively.

Discussion

Students should be introduced to high calcium products in their community such as hard tofu, minnow, and small freshwater shrimp. Educational programs on nutrition label interpretation are needed.

Vitamin D status in full-term exclusively breastfed infants versus full-term breastfed infants receiving vitamin D supplementation in Thailand: a randomized controlled trial

Background

Many international medical organizations recommend vitamin D supplementation for infants, especially exclusively breastfed infants. In Thailand, however, data regarding the vitamin D status in Thai infants are lacking. Such data would help to support physician decisions and guide medical practice.

Methods

Full-term, exclusively breastfed infants were randomized into two groups at 2 months of age to continue exclusive breastfeeding either without vitamin D supplementation (control group, n = 44) or with vitamin D₃ supplementation at 400 IU/day (intervention group, n = 43) until 6 months of age. At 6 months, the serum vitamin D (25OHD) of the infants and their mothers, serum bone marker, and infants’ growth parameters were compared between the two groups.

Results

The infants’ serum 25OHD concentration was lower in the control group than intervention group (20.57 ± 12.66 vs. 46.01 ± 16.42 ng/mL, p < 0.01). More infants had vitamin D sufficiency (25OHD of > 20 ng/mL) in the intervention group than control group (93.0% vs. 43.2%, p < 0.01). There were no significant differences in the maternal 25OHD concentrations between the control and intervention groups (25.08 ± 7.75 vs. 23.75 ± 7.64 ng/mL, p = 0.42). Serum calcium, phosphorus, intact parathyroid hormone, alkaline phosphatase, and infants’ growth parameters were comparable between the two groups. After adjustment for the confounding factors, 25OHD concentration in the intervention group was 25.66 ng/mL higher than the control group (95% confidence interval, 19.07–32.25; p < 0.001). Vitamin D supplement contributed to an 88.7% decrease in the prevalence of vitamin D insufficiency/deficiency (relative risk, 0.11; 95% confidence interval, 0.04–0.35; p < 0.01).

Conclusions

Most full-term, exclusively breastfed Thai infants have serum vitamin D concentration below sufficiency level at 6 months of age. However, vitamin D supplementation (400 IU/day) improves their vitamin D status and prevents vitamin D deficiency.

Trial registration

The study was pre-registered in the Thai Clinical Trials Registry (TCTR20190622001) on 22/06/2019.

Determination of Hemoglobin Level Among 9-Month-Old Infants Visiting Well Child Clinic

Screening for anemia is recommended among infants aged 9 to 12 months. This study was conducted to determine the prevalence of anemia among 9-month-old infants at Well Child Clinic, and associated factors with anemia. Well Child record of all visits during January to December 2018 were reviewed. Hemoglobin (Hb) was determined by complete blood count (CBC) or point-of-care Hb (POC-Hb). Anemia was found in 99 from 145 infants (68.3%). The prevalence of anemia was 33.3% and 72.8% when tested by CBC and POC-Hb, respectively. Breastfed Infants had significantly lower mean Hb than formula-fed infants. The odd ratio [95% confident interval] of having anemia among infants who were fed with infant formula were 0.37 [0.14-0.94]; P = .038 when compared to breastfed infants. There was a high proportion of anemia among 9-month-old infants in Rama-WCC and breastfeeding was associated with anemia in infants. The use of POC-Hb may overestimate the prevalence of anemia.

Adherence to Screening for Anemia in 9-Month-Old Full-Term Infants in Bangkok, Thailand

OBJECTIVES

To determine adherence to the screening for anemia in 9-month-old full-term infants and factors associated with non-adherence to the screening for anemia.

METHODS

A descriptive cross-sectional study was conducted in 9-month-old full-term healthy infants who visited the General Pediatric and Well Child Care Clinic, King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Demographic data, adherence to the screening, and factors associated with non-adherence to the screening were analyzed using percentage, χ2 test, and bivariate logistic regression.

RESULTS

A total of 234 full-term infants, aged 9 months, were included in the study between January and December 2019. The prevalence of adherence to the screening for anemia was 76.1% (95% CI 0.70-0.81). The most common cause of non-adherence to the screening was the waiting time for laboratory results (39.3%). Factors associated with non-adherence to the screening were low education of caregiver (AOR 2.684; 95% CI 1.451-4.966), low socio-economic status (AOR 2.26; 95% CI 1.568-3.258), and inadequate complementary food (AOR 1.961; 95% CI 1.107-3.473).

CONCLUSION

The most common cause of non-adherence to the screening for anemia is the waiting time for laboratory results. Pediatricians and general practitioners should ensure the importance of anemia screening in infants and plan on anemia screening with parents.

The Association between Hepcidin and Iron Status in Children and Adolescents with Obesity

Introduction

Iron deficiency (ID) is the most common nutritional deficiency found in pediatric practice. A higher prevalence of ID may be found in children with obesity. Obesity is a chronic low-grade inflammatory condition. It is postulated that inflammation increases hepcidin, a regulator of iron homeostasis. The aim of this study was to investigate the associations between iron status, hepcidin, and BMI-standard deviation score (BMI-SDS) in children with and without obesity.

Methods

A cross-sectional study of Thai children with obesity (5 to 15 years old) versus age- and sex-matched, nonobese controls was conducted. A total of 63 children with obesity and 27 controls were enrolled. Complete blood count, serum iron, ferritin, transferrin saturation, and total iron binding capacity were analyzed. Serum hepcidin-25 was assayed using a hepcidin ELISA Kit (Human Hepc25).

Results

There were 63 children with obesity, the median age (IQR) being 10 (9–13) years, and 27 controls. The median (IQR) BMI-SDS of the obese group was 2.3 (2.0–2.6) vs. −0.5 ((−1.3)−0.4) of the control group. ID was diagnosed in 27 children in the obese group (42.9%); 4 of the children with obesity and ID had anemia. Serum hepcidin-25 levels of the children with ID vs. without ID in the obese group were not significantly different (median (IQR) 25 (12.9–49.2) and 26.4 (12.6–43.6), respectively) but both of them were significantly higher than controls (19.7 (8.3–25.5) ng/ml, p = 0.04). BMI-SDS was positively correlated with hepcidin-25 (r = 0.28, p = 0.001).

Conclusion

Prevalence of iron deficiency in Thai children with obesity and serum hepcidin-25 was higher than controls. Further study in a larger population, preferably with interventions such as weight loss program, is warranted to clarify this association.

Effects of vitamin D and calcium supplementation on bone mineral density among Thai youth using daily HIV pre-exposure prophylaxis

INTRODUCTION

Tenofovir disoproxil fumarate with emtricitabine (TDF/FTC) is used for HIV pre-exposure prophylaxis (PrEP). TDF may affect bone mineral density (BMD), particularly in youth who are at a stage of peak bone mass accrual. The objective of this study was to evaluate the effect of vitamin D and calcium supplementation on BMD among Thai youth receiving daily oral PrEP.

METHODS

This open-label randomized trial was conducted in male youth aged between 15 and 24 years. Participants were randomized to Arm A who received once-daily TDF/FTC plus vitamin D3 and calcium supplementation with meals twice daily (400 units of vitamin D3 and 1200 mg of elemental calcium/day) or Arm B who received once-daily TDF/FTC only. PrEP users were defined as taking at least two tablets/week (tenofovir-diphosphate level of >350 fmol/punch). Adherence to vitamin D/calcium supplementation was defined as self-reported adherence of >50%. Lumbar spine (L2-L4) BMD (LSBMD) was evaluated by dual-energy X-ray absorptiometry scan zero and six months after PrEP initiation.

RESULTS

From March 2019 to March 2020, 100 youth were enrolled. Baseline characteristics between the two arms were similar. Median (IQR) age was 18 (17 to 20) years. At entry, median (IQR) LSBMD z-score was -0.8 (-1.5 to -0.3), 17% had low LSBMD (Z-score < -2). The median amount of calcium intake from nutritional three-day recall was 167 (IQR 94 to 272) mg/day, 39% of participants had vitamin D deficiency, defined as 25(OH)D levels <20 IU/mL. At six months, 79 participants were evaluated. Of these, 42 (52%) were PrEP takers and 25 of 38 (66%) of arm A participants had good adherence to vitamin D/calcium supplementation. Significantly higher proportions of youth in arm A compared to arm B had >3% increase in LSBMD at month 6 compared to baseline (67.6% vs. 42.9% respectively; p = 0.03). There were significantly higher increases in LSBMD among youth with vitamin D deficiency who were supplemented; arm A + 0.05 (0 to 0.05) compared to arm B + 0.03 (-0.1 to 0.03), p = 0.04.

CONCLUSIONS

Increases in LSBMD over six months among youth using PrEP who received vitamin D/calcium supplementation was greater than those not supplemented. Long-term follow-up should be considered to explore long-term outcomes.

Child feeding practices and concerns: Thematic content analysis of Thai virtual communities

Parents' child feeding practices are influenced not only by family but also by a broader circle of networks, including online groups. Peer-to-peer platforms such as Facebook groups facilitate a learning environment and may influence the transmission of user-generated content into practice. These digital data not only benefit participants but also offer new opportunities for researchers to study related phenomena. Therefore, this study employs thematic content analysis to investigate peer-exchanging discourse conveyed in Facebook peer-support groups in children's diets in Thailand. To identify the area of interest, we classified and quantified the initial posts and investigated the relationship between initial posts' contents and community engagement. Thematic analysis was used to qualitatively describe the peer-exchanging content that responded to the initial posts. Of the five approved Facebook groups, 200 initial posts with their 1964 comments were extracted anonymously. Results revealed that Facebook groups devoted to diets for children have become a platform for Thai parents to seek informational and emotional support. The top-ranked initial posts were related to requesting knowledge and skills about age-appropriate food and meal preparation. Parents have also expressed anxiety about feeding and tension related to food fussiness which created the need for emotional support. Age-appropriate feeding, homemade baby foods, concerns about food seasonings and food allergy awareness were observable within online groups. However, a shift from traditional child feeding practices to new ideas created cultural gaps which lead to arguments in some families. Understanding these views would help guide to address parental concerns better.

Commercial growing up milks: usage frequency and associated child and demographic factors across four Asia Pacific countries

BACKGROUND

Commercial growing up milks (GUMs) targeted at children from 12 to 36 months of age are a rapidly growing industry, particularly across the Asia Pacific.

METHODS

The present study assessed the frequency of use and socio-demographic and child associations of commercial GUM feeding in children, aged between 12 and 36 months, in capital cities in four Asia Pacific countries. Mothers of children aged between 12 and 36 months were surveyed, assessing GUM feeding frequency in the past month. A market research company database was used to survey across Asia Pacific urban cities, including Bangkok Thailand, Jakarta Indonesia, Singapore and Australian Capital Cities (ACC).

RESULTS

More than 1000 women (n = 1051) were surveyed (Bangkok, n = 263; Jakarta, n = 275; ACC, n = 252; Singapore, n = 261). The mean (SD) age of mothers was 32.4 (5.3) years and that of children was 23.6 (6.7) months. In total, 62.7% of the children were fed GUMs more than once per week with significant country variance. In comparison with ACC, Asian countries were significantly more likely to feed GUMs ≥once per week: Bangkok [odds ratio (OR) = 5.7, 95% confidence interval (CI) = 3.8-8.6]; Jakarta (OR = 3.5, 95% CI = 2.3-5.5); and Singapore (OR = 7.4, 95% CI = 4.9-11.1). Associations of GUM feeding included: maternal tertiary education; mothers younger than 30 years; working full time; and feeding of commercial infant formula under 12 months.

CONCLUSIONS

This is the first published study to explore commercial GUM feeding in and between countries. The incidence of GUM feeding, in contrast to international recommendations, signals the need for further research into the drivers for GUM feeding and its contribution to the diet.

Current calcium fortification experiences: a review

Low dietary calcium is very common in many populations, contributing to nutritional rickets/osteomalacia in children/adults and increasing the risk of several health problems. Calcium is a nutrient of concern as the recommended nutrient requirements are difficult to meet in the absence of dairy products. The provision of culturally acceptable calcium-fortified foods may improve calcium intake when it is a feasible and cost-effective strategy in a particular setting. This landscape review was conducted in 2019 and describes current calcium fortification efforts and lessons learned from these experiences. Worldwide, the United Kingdom is the only country where calcium fortification of wheat flour is mandatory. It is estimated that this fortified staple ingredient contributes to 13-14% of calcium intake of the British population. Other items voluntary fortified with calcium include maize flour, rice, and water. Current calcium fortification programs may lack qualified personnel/training, clear guidelines on implementation, regulation, monitoring/evaluation, and functional indicators. Also, the cost of calcium premix is high and the target groups may be hard to reach. There is a lack of rigorous evaluation, particularly in settings with multiple micronutrient programs implemented simultaneously, with low quality of the evidence. Further research is needed to assess the impact of calcium fortification programs.

Nutrient and Mineral Compositions of Wild Leafy Vegetables of the Karen and Lawa Communities in Thailand

Wild food plants are commonly used in the traditional diets of indigenous people in many parts of the world, including northern Thailand. The potential contribution of wild food plants to the nutrition of the Karen and Lawa communities remains poorly understood. Wild food plants, with a focus on leafy vegetables, were ranked by the Cultural Food Significance Index (CFSI) based on semi-structured interviews. Twelve wild plant species were highly mentioned and widely consumed. The importance of the wild vegetables was mainly related to taste, availability, and multifunctionality of the species. Their contents of proximate and minerals (P, K, Na, Ca, Mg, Fe, Mn, Zn, and Cu) were analyzed using standard methods. The proximate contents were comparable to most domesticated vegetables. The contents of Mg (104 mg/100 g FW), Fe (11 mg/100 g FW), and Zn (19 mg/100 g FW) in the wild leafy vegetables were high enough to cover the daily recommended dietary allowances of adults (19-50 years), whereas a few species showed Mn contents higher than the tolerable upper intake level (>11 mg/100 g edible part). The wild leafy vegetables, therefore, are good sources of minerals and we recommend their continued usage by indigenous people. Further research on these wild leafy vegetables' contents of antioxidants, vitamins, heavy metals, anti-nutrient factors, and food safety is recommended.

The Impact of Dietary Protein in Complementary Foods on Infant Growth and Body Composition in a Population Facing the Double Burden of Malnutrition: Protocol for a Multicenter, Prospective Cohort Study

BACKGROUND

Protein is an essential macronutrient with an important role during complementary feeding. Low protein intake contributes to undernutrition while high intake, especially from animal sources, may increase obesity risk. However, the influences of different protein sources (dairy, meat, and plants) on growth, and underlying mechanisms for these effects, are poorly understood. Animal-sourced foods provide both high-quality protein and iron and are recommended to improve iron status. However, it is unclear whether current dietary recommendations are adequate to support healthy growth and optimize iron status. These issues are of particular concern in countries facing the double burden of malnutrition, the coexistence of all forms of malnutrition. More evidence is needed to develop appropriate recommendations for these countries.

OBJECTIVE

This study will investigate associations between protein intake during complementary feeding and growth, body composition, and iron status of infants in Thailand, a country facing the double burden of malnutrition. The study will also explore how different protein sources influence growth via the growth hormone-insulin-like growth factor I (IGF-1) axis and plasma amino acids.

METHODS

A multicenter cohort study will be conducted in Chiang Mai, Thailand, in 150 healthy term infants aged 4-6 months with birth weight ≥2500 g. Demographic data, dietary intake, and anthropometry will be collected at 6, 9, and 12 months. Dietary intake will be assessed using 24-hour dietary recalls, 3-day food records, and food frequency questionnaires. Blood samples for iron status, growth hormone, IGF-1, insulin-like growth factor-binding protein III (IGFBP-3), and plasma amino acids and urine samples for body composition analysis using stable isotope dilution will be obtained at 12 months.

RESULTS

The recruitment of study participants and data collection was undertaken from June 2018 to May 2019. Data and laboratory analyses are ongoing and are expected to be completed by December 2020. A total of 150 participants were enrolled, and 146 completed the study. We hypothesized that protein intake from animal-sourced foods in recommended quantities could support normal weight and length gain and lower the risk of undernutrition associated with similar amounts of plant-based protein. However, higher protein intake, especially from milk protein, may be linked to increased body fat via plasma amino acids and the growth hormone-IGF axis.

CONCLUSIONS

The results of this study will provide data on current complementary feeding practices, focusing on protein and iron intake in Thai infants. This information, combined with data on associations with infant growth and iron status, will help inform complementary feeding recommendations for this population and may be found relevant to other settings experiencing the double burden of malnutrition.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/18112.

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.

Rural-Urban Differences in Dietary Behavior and Obesity: Results of the Riskesdas Study in 10-18-Year-Old Indonesian Children and Adolescents

Obesity has become a significant problem for developing countries, including Indonesia. High duration of sedentary activity and high intake of unhealthy foods were associated with high risk of overweight and obesity. The objective of this study was to compare the distributions of sedentary activity and dietary behavior with overweight/obesity risks between urban and rural areas among children and adolescents aged 10-18 years in Indonesia. This is a cross-sectional study. Data from a national survey in 33 Indonesian provinces (Basic Health Research /Riskesdas 2013) were analyzed. Multiple logistic regression models were used to calculate the odds ratio (OR) adjusted with all variables, such as age, gender, residency, education level, physical activity, and food intake. An urban-rural residence difference was found in the factors related to obesity. Daily caffeinated soft drinks and energy drinks consumption (OR = 1.12, 95% CI: 1.01-1.23) were related to risk of overweight and obesity in urban areas. Daily grilled foods (OR = 1.32, 95% CI: 1.22-1.42) and salty food (OR = 1.09, 95% CI: 1.04-1.15) consumption were significantly associated with obesity in rural areas but not in urban areas. Furthermore, sedentary activity was correlated with overweight and obesity among those who lived in urban and rural areas. Our findings suggest that education, environmental, and policy interventions may need to specifically target urban settings, where access is high to a wide range of processed and traditional high-sugar, high-fat snack foods and beverages.

Socio-Ecological Model of Correlates of Double Burden of Malnutrition in Developing Countries: A Narrative Review

(1) Background: The double burden of malnutrition (DBM) is a complex problem involving the coexistence of under- and over-nutrition within the same individual, household or population. This review aimed to discuss the correlates of the double burden of malnutrition through the socio-ecological model (SEM); (2) Methods: The PubMed database was systematically searched for peer-reviewed articles related to the double burden of malnutrition. Information on correlates of the double burden of malnutrition was extracted for analysis and discussion in alignment with the levels of the socio-ecological model.; (3) Results and Discussion: The correlates of the double burden of malnutrition identified from previous literature were: Race/genetics; maternal short stature; breastfeeding status; low maternal education; family size; household food security; household dietary diversity; and rural and urban settings. In the absence of evidence linking factors in a certain level of the SEM and the double burden of malnutrition, we employed correlates of overweight status and obesity to complete this narrative. Potential intervention strategies were proposed in alignment with the targets and settings identified, based on the socio-ecological approach; (4) Conclusions: The double burden of malnutrition is a public health phenomenon associated with a variety of socio-ecological determinants. An integrated approach is needed to address the root causes of malnutrition in all its forms, and at all life stages.

Dental caries and vitamin D status in children in Asia

Dental caries and vitamin D inadequacy are known to affect children worldwide. Vitamin D has a vital role in tooth formation. There is growing evidence linking suboptimal serum vitamin D level with dental caries in children. This paper reviews the literature on both the prevalence of dental caries and of vitamin D deficiency in children in four Asian regions, discusses their associated risk factors, and reviews the global evidence on the association between dental caries and vitamin D in children. Caries prevalence in children ranged from 40% to 97% in Eastern Asia, 38-73.7% in Southern Asia, and 26.5-74.7% in Western Asian countries. Moreover, a higher prevalence of vitamin D deficiency in Asian children was identified, even in countries in equatorial regions, ranging from 2.8% to 65.3% in Eastern Asia, 5-66.7% in Southern Asia, 4-45.5% in Western Asia and 38.1-78.7% in Central Asian countries. Obesity, age, female gender, higher latitude, season, darker skin pigmentation, sunlight protection behaviors, less sunlight exposure and low intake of food containing vitamin D were important factors associated with lower serum vitamin D in Asia. Suboptimal vitamin D level in children may be a significant risk factor for dental caries, and requires further research to ascertain such an association in children in Asia, as well as to understand its exact influence on caries risk and development.

A cross-sectional study of urinary cadmium concentrations in relation to dietary intakes in Uruguayan school children

BACKGROUND

Cadmium (Cd) exposure has adverse health effects in children. Diet contributes to Cd exposure, but dietary components could affect body Cd levels.

OBJECTIVE

To examine associations between diet and urinary Cd (U-Cd) in children.

METHODS

In this cross-sectional study conducted in Montevideo, Uruguay, Cd exposure of 5-8 year old children (n = 279 with complete data) was assessed in first morning urine (U-Cd), a marker of long-term exposure, measured by ICP-MS and adjusted for specific gravity. Distribution of U-Cd was (median [5%, 95%]: 0.06 [0.02, 0.17] μg/L); data were natural-log-transformed (ln) for statistical analyses. Serum ferritin (SF), an indicator of iron stores, was measured in fasting samples. Trained nutritionists completed two non-consecutive 24-h dietary recalls with both child and caregiver present. Measures of iron, zinc, calcium and fiber intake, and the consumption of grains, root vegetables, milk, and foods rich in heme iron (white and read meats) and non-heme iron (legumes, spinach, broccoli, tomatoes, dried fruit) were derived. Multivariable ordinary least squares (OLS) and ordinal regressions were used to examine associations among tertiles of water Cd, SF, diet, and U-Cd. OLS models were further stratified by sex.

RESULTS

In covariate-adjusted models, SF was not related to ln-U-Cd. Children in highest tertile of iron and zinc intake had lower ln-U-Cd: (-0.23 [-0.42, -0.03]) and (-0.25 [-0.44, -0.05]), respectively, compared to the reference group. Children consuming higher amounts of foods rich in heme iron had slightly lower ln-U-Cd (-0.17 [-0.36, 0.03]). High grain consumption was related to higher ln-U-Cd (0.25 [0.06, 0.45]).

CONCLUSIONS

Diets rich in grains were related to higher urinary Cd levels among children living in the context of low Cd pollution. Higher intake of iron and zinc was related to lower Cd levels. Given that urinary Cd is mainly a marker of long-term exposure, these findings should be further corroborated.

Vitamin D status of children in Kerala, southern India

Objective

To study plasma 25-hydroxyvitamin D (25(OH)D) status of children in Kerala, southern India, and its relationship with sociodemographic variables.

Design

Cross-sectional observational study.

Setting

Tertiary government hospital.

Participants

Children (n 296) with trivial acute illness were enrolled. Sun exposure and Ca and vitamin D intakes (7 d dietary recall) were documented. Serum Ca, P, alkaline phosphatase, plasma 25(OH)D and parathyroid hormone (PTH) were measured.

Results

Prevalence of vitamin D deficiency (plasma 25(OH)D <30 nmol/l) was 11·1% (median, interquartile range (IQR): 52·6, 38·4–65·6 nmol/l). Children who ate fish daily had significantly higher plasma 25(OH)D than those who did not (median, IQR: 52·5, 40·8–68·9 v. 49·1, 36·2–60·7 nmol/l; P = 0·02). Those investigated in the months of March–May showed highest 25(OH)D v. those enrolled during other times (median, IQR: 58·7, 45·6–81·4 v. 45·5, 35·6–57·4 nmol/l; P <0·001). Plasma 25(OH)D correlated positively with serum P (r = 0·24, P <0·001) and Ca intake (r = 0·16, P 0·03), negatively with age (r = −0·13, P 0·03) and PTH (r = −0·22, P <0·001.). On linear regression, summer season (March–May), lower age, daily fish intake and higher Ca intake were independently associated with plasma 25(OH)D.

Conclusions

Prevalence of vitamin D deficiency is low in Kerala. The natural fish diet of coastal Kerala and the latitude may be protective. Public health policy in India should take account of this geographical diversity.

Childhood stunting in Thailand: when prolonged breastfeeding interacts with household poverty

BACKGROUND

Childhood stunting, defined as the height-for-age standardized score lower than minus two, is one of the key indicators for assessing well-being and health of a child; and can be used for monitoring child health inequalities. Thailand has been successful in improving health and providing financial protection for its population. A better understanding of the determinants of stunting will help fill both knowledge and policy gaps which promote children's health and well-being. This study assesses the factors contributing to stunting among Thai children aged less than five years.

METHODS

This study obtained data from the Multiple Indicator Cluster Survey Round 4 (MICS4), conducted in Thailand in 2012. Data analysis consisted of three steps. First, descriptive statistics provided an overview of data. Second, a Chi-square test determined the association between each covariate and stunting. Finally, multivariable logistic regression assessed the likelihood of stunting from all independent variables. Interaction effects between breastfeeding and household economy were added in the multivariable logistic regression.

RESULTS

In the analysis without interaction effects, while the perceived size of children at birth as 'small' were positively associated with stunting, children in the well-off households were less likely to experience stunting. The analysis of the interactions between 'duration of breastfeeding' and 'household's economic level' found that the odds of stunting in children who were breastfed longer than 12 months in the poorest household quintile were 1.8 fold (95% Confidence interval: 1.3-2.6) higher than the odds found in mothers from the same poorest quintiles, but without prolonged breastfeeding. However prolonged breastfeeding in most well-off households (those between the second quintile and the fifth wealth quintile) did not show a tendency towards stunting.

CONCLUSIONS

Childhood stunting was significantly associated with several factors. Prolonged breastfeeding beyond 12 months when interacting with poor economic status of a household potentiated stunting. Children living in the least well-off households were more prone to stunting than others. We recommend that the MICS survey questionnaire be amended to capture details on quantity, quality and practices of supplementary feeding. Multi-sectoral nutrition policies targeting poor households are required to address stunting challenges.

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.

Stunting, dietary diversity and household food insecurity among children under 5 years in ethnic communities of northern Thailand

Background

The aim of this study was to describe stunting in infants and young children in the ethnic communities of northern Thailand and to explore associations with dietary diversity and household factors including food security.

Methods

A cross-sectional survey of households with children under 5 years from eight villages. Adult respondents provided information on foods consumed by each child and details of the household. Heights and weights of children were measured.

Results

Adults from 172 households and 208 children participated. Overall, 38% of children were stunted. Exclusive breastfeeding was rare, but the proportion consuming breastmilk at 24 months (75%) was high. Few children (7%) aged 6–11 months met minimum dietary diversity. Stunted children were less likely than non-stunted children to meet minimum dietary diversity (63 versus 82%). Widespread food insecurity did not discriminate between stunted and non-stunted children. Stunting was elevated when households had little land and few animals.

Conclusions

Stunting was widespread in children under 5 years of age, in part reflecting poor dietary diversity, especially at age 6–11 months. Stunting was worst in households with least assets. Small increases in land or animals, or equivalent resources, appear to be required to improve child nutrition in extremely poor families.

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.

Prevalence of vitamin D deficiency in cord blood of newborns and the association with maternal vitamin D status

Vitamin D deficiency is common in Southeast Asia but there are limited data in pregnant women and neonates. This study aimed to determine the prevalence of vitamin D deficiency in cord blood of newborns and the association with maternal vitamin D status. A total of 94 pregnant women and their neonates were included. Clinical data and venous maternal blood for calcium, phosphate, albumin, alkaline phosphatase, magnesium, intact parathyroid hormone (iPTH), and vitamin D (25OHD) were obtained on the day of labor. Cord blood was collected following delivery to evaluate vitamin D status of newborns. Mean serum maternal and cord blood 25OHD levels were 25.42 ± 8.07 and 14.85 ± 5.13 ng/mL. The prevalence of vitamin D deficiency (25OHD < 12 ng/mL) and insufficiency (25OHD 12-20 ng/mL) in cord blood of newborns were 20.2 and 69.1%, respectively. There was a significant correlation between maternal and cord blood vitamin D levels (r = 0.86; P < 0.001). The factors associated with cord blood vitamin D deficiency were low maternal 25OHD level and no vitamin D supplement during pregnancy.

CONCLUSION

There is a high prevalence of vitamin D deficiency among Thai neonates. Adequate prenatal vitamin D supplementation should be implemented as routine antenatal care. What is Known: • Vitamin D deficiency is prevalent in Southeast Asia. • There are widespread vitamin D deficiency among Thai populations including pregnant women. What is New: • There is a high prevalence of vitamin D deficiency among Thai neonates. • The factors associated with cord blood vitamin D deficiency are low maternal vitamin D level and no vitamin D supplement during pregnancy.

Complementary feeding: Attitudes, knowledge and practices of urban families in northern Thailand

AIM

Urban families in middle-income countries are currently facing cultural and lifestyle transition. Changing from an agricultural to an industrial society may affect family roles and child-care practices. The present study aims to reveal family attitudes, knowledge and practices focusing on complementary feeding (CF).

METHODS

A cross-sectional study was conducted in three Child Health Clinics in Chiang Mai, Thailand. Self-administered questionnaires were given to families caring for healthy infants and children less than 18 months of age during October to November 2016.

RESULTS

One-hundred and eight respondents completed questionnaires. The study found different attitudes and knowledge gaps between the respondents who were mothers and other family members ('others'). The 'others' were less likely to value CF as a crucial factor promoting child growth and development. Moreover, they had misperceptions about the benefits of animal-based protein and were less confident in their ability to feed the child properly. Most families reported timely introduction of complementary food, using proper milk products and encouraging age-appropriate feeding methods. However, there were undesirable practices including delaying introduction of animal-based protein, inadequate food diversity, the use of seasoning, feeding premasticated food and offering food as a reward.

CONCLUSIONS

These findings suggest that nutritional education should be extended to all caregivers involved in CF to improve the adherence to feeding recommendations.

Local perspectives and context in relation to feeding practices of children under 2 years in the mountain villages of northern Thailand

OBJECTIVE

To gain an in-depth understanding of infant and young child feeding practices, accompanying beliefs and their sociocultural context in the Karen and Lua ethnic communities of northern Thailand.

DESIGN

A two-day workshop and thirty in-depth interviews were undertaken in June 2014. Dialogue occurred with the assistance of translators and was recorded, transcribed and translated. A detailed thematic analysis was undertaken.

SETTING

Northern Thai indigenous communities in which one-third of the children under 5 years of age are stunted.

SUBJECTS

People with various roles in the local health system and twenty-six villagers who cared for infants and young children.

RESULTS

Predominant breast-feeding was said to occur for 1 to 3 months but was not exclusive due to early introduction of water and/or rice. Exclusive breast-feeding for 6 months was impeded by the need for mothers to return to farming work, with the early introduction of solids enabling infants to be cared for by other family members. Low variety in complementary foods was typical during infancy, with few local foods having appropriate texture and special preparation of foods rarely described. A pervasive underlying issue is women's responsibility to labour and lack of time to care for their young children. Poverty and food insecurity also featured in participants' accounts.

CONCLUSIONS

In combination, women's limited time to care, poverty and food insecurity are perpetuating poor nutrition of children in early life. Agricultural solutions that are being explored should also attend to the burden of work for women.

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.

Lifestyle behaviors and serum vitamin C in the Thai population in Bangkok Metropolitan

This study aimed to investigate the influence of lifestyle behaviors on the vitamin C levels in the circulating blood of the Thai population in Bangkok Metropolitan. The participants (n=250) included community workers (i.e., construction and business office workers) from the Bangkok Metropolitan, and the participants were placed in various behavior and lifestyle groups (Group I: reference; Group II: alcohol drinkers; Group III: outdoor workers; Group IV: smokers; and Group V: combined). The results showed that the lowest and highest vitamin C intakes were 7 and 27 mg/day in Groups IV and III, respectively. Group I (indoor workers free of smoking and drinking), had the highest total serum vitamin C level (39.7 µmol/L), while Group V (outdoor workers with smoking and drinking), had the lowest value (12.5 µmol/L). Furthermore, Group V had the highest prevalence (44 %) of total serum vitamin C deficiency (<11 µmol/L), while Group I had the lowest deficient indication (8 %). The vitamin C dietary intake and total serum levels were positively correlated in the reference group (Spearman's correlation=0.402, p < 0.05) but not in the other four groups. The significant adjusted odds ratio of inadequate total serum vitamin C (< 23 µmol/L) was 2.90 (CI: 1.15, 7.31) in Group IV and 3.73 (CI: 1.42, 9.81) in Group V. Moreover, the tendency to have an inadequate total serum vitamin C level was demonstrated in the following order: Group I < II < III < IV < V. Our results indicated that outdoor workers (Group III) and smokers (Group IV) had a greater likelihood of having a vitamin C deficiency than the reference group. A high percentage of deficiency was clearly observed among the outdoor workers with smoking and drinking behaviors (Group V).

Household Food Insecurity as a Predictor of Stunted Children and Overweight/Obese Mothers (SCOWT) in Urban Indonesia

(1) Background: The double burden of malnutrition has been increasing in countries experiencing the nutrition transition. This study aimed to determine the relationship between household food insecurity and the double burden of malnutrition, defined as within-household stunted child and an overweight/obese mother (SCOWT). (2) Methods: A cross-sectional survey was conducted in the urban city of Surabaya, Indonesia in April and May 2015. (3) Results: The prevalence of child stunting in urban Surabaya was 36.4%, maternal overweight/obesity was 70.2%, and SCOWT was 24.7%. Although many households were food secure (42%), there were high proportions of mild (22.9%), moderate (15.3%) and severe (19.7%) food insecurity. In a multivariate logistic regression, the household food insecurity access scale (HFIAS) category significantly correlated with child stunting and SCOWT. Compared to food secure households, mildly food insecure households had the greatest odds of SCOWT (adjusted odds ratio (aOR) = 2.789; 95% confidence interval (CI) = 1.540⁻5.083), followed by moderately food insecure (aOR = 2.530; 95% CI = 1.286⁻4.980) and severely food insecure households (aOR = 2.045; 95% CI = 1.087⁻3.848). (4) Conclusions: These results support the hypothesis that the double burden of malnutrition is related to food insecurity, and the HFIAS category is a predictor of SCOWT.

Food Sources of Energy and Macronutrient Intakes among Infants from 6 to 12 Months of Age: The Growing Up in Singapore Towards Healthy Outcomes (GUSTO) Study

Adequate nutrition during complementary feeding is important for the growth, development and well-being of children. We aim to examine the energy and macronutrient intake composition and their main food sources in a mother-offspring cohort study in Singapore. The diets of infants were assessed by 24 h dietary recalls or food diaries collected from mothers when their offspring were 6 (n = 760), 9 (n = 893) and 12 (n = 907) months of age. Food sources of energy and macronutrients were determined using the population proportion methodology. Energy intakes per day (kcal; mean (standard deviation, SD)) of these infants were 640 (158) at 6 months, 675 (173) at 9 months, and 761 (208) at 12 months. Infant formula, breastmilk and infant cereals were the top three food sources of energy and macronutrient intakes in infants through the period 6 to 12 months. Other main energy and carbohydrate sources at 9 and 12 months of age were rice porridge, infant biscuits and fresh fruits, while fish, red meat and eggs were the other main protein and total fat sources. Breast-fed and mixed-fed infants had a more varied diet as compared to formula-fed infants. Formula-fed infants had consistently higher protein and lower total fat consumption compared to those who were breastfed. An understanding of these main food sources during complementary feeding can inform local dietary recommendations and policies.

Parental feeding practice is associated with child’s body mass index in Thai school-aged children

Purpose

Parental feeding practice (PFP) plays an important role in child’s eating behavior and weight status, but less information is available about its role in the Thai family setting. The purpose of this paper is to examine the influence of PFP on child’s gender and body mass index (BMI).

Design/methodology/approach

Participants included 227 parents-child dyads from the suburban area of Nakhon Pathom province, Thailand. Children aged 9-12 years and parents who were either child’s mother, father or grandfather/grandmother were enrolled in the study. Body weight, height, waist circumference and body fat were measured in all children. Eating behavior of each child was assessed by using child’s eating questionnaire. Parents also provided their feeding practices in child feeding questionnaires. Information on household food security was also obtained from children’s parents.

Findings

There was significant difference in eating behaviors and home environment between child’s genders. For child’s eating behavior, mean total eating scores of girls were significantly greater (p=0.002) than that of boys and that the inappropriate home environment was more found in families of boys than girls. Regarding feeding practice, parents used more food restriction (p=0.008) and monitoring on child’s eating (p=0.042) in girls than boys. Parents put more pressure to eat on the normal weight than obese children (p=0.001). Regression analysis revealed that, apart from parental BMI and household income, PFPs have a significant impact (15.6 percent explained variance) on child’s BMI.

Originality/value

This study highlights the importance of being aware of child’s gender and weight status when feeding practices were provided to them. Nutrition education for parents should take account for parents’ perceptions and concerns as well as the modification of feeding practices to improve children’s eating behaviors.

Hair Zinc and Severity of Symptoms Are Increased in Children with Attention Deficit and Hyperactivity Disorder: a Hair Multi-Element Profile Study

Determination of bioelement levels in hair is an emerging non-invasive approach for screening bioelement deposition. However, the role of essential bioelement levels in hair and attention deficit/hyperactivity disorder (ADHD) risk or severity is largely unknown. In this study, we have compared multi-element hair profiles between healthy and ADHD Thai children. In addition, the correlations between bioelements and ADHD symptoms according to Diagnostic and Statistical Manual of Mental Disorders, 5th edition, diagnostic criteria were identified. A case-control study was conducted in 111 Thai children (45 newly diagnosed ADHD and 66 matched healthy), aged 3-7 years, living in Bangkok and suburban areas. Levels of 39 bioelements in hair were measured by ICP-MS. Among the analyzed bioelements, Cu/Zn and P/Zn ratios in ADHD children were significantly lower than those in healthy children. Indeed, increased hair Zn level was correlated with more symptoms of inattention, hyperactivity, and total ADHD symptoms. Higher Zn content was also associated with being female and older age. Furthermore, Zn in hair was positively correlated with levels of Ca, Mg, and P; however, it showed a negative correlation with Al, As, Fe, and Mo. These findings warrant further confirmation in a large-scale study. Thai Clinical Trials Registry (TCTR) study ID: 20151113001.

Dietary intake and weight status of urban Thai preadolescents in the context of food environment

Little attention has been devoted to the importance of understanding the association between dietary intake and childhood obesity in Thailand. This study aimed to explore food types affecting the weight status of preadolescents in urban settings, where obesity is remarkably prevalent. This study was conducted in 2015–2016 and assessed the dietary intake of 263 children aged 10–12 years from Bangkok Metropolitan Regions through three- nonconsecutive-day 24 h recall. Lifestyle and sociodemographic information was obtained using questionnaires. Participants were classified into non-obese and overweight/obese groups based on the WHO child growth standard curve. Foods were categorized into 13 groups based on Thailand's dietary guidelines and food environment context regarding two eating occasions (main and between meals) of children, which resulted in the newly classified “street-side snacks”. Data were examined using analysis of covariance and multiple linear regression analysis. After adjusting for sex and energy misreporting, overweight/obese participants had higher energy and macronutrient intake and consumed more cereal grains, meat/fish, flavored milk, and sugar-sweetened beverages during main meals and street-side snacks and confectioneries during between meals than non-obese participants. The consumption of street-side snacks had the highest beta coefficient on BMI z-scores among the food types in the model, adjusted further for energy intakes. Street-side snacks may be an important predictor of obesity in Thai children. A prospective investigation of the impact of accessibility and availability of this food item is needed.

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.

Dietary iron intake and availability are related to maternal education level in overweight/obese adolescents

PURPOSE

To compare intakes of dietary iron and enhancers and inhibitors of iron absorption between overweight/obese (OW/OB) adolescents and their normal weight (NW) peers, and between parental education levels stratified by weight status.

METHODS

This was a comparative cross-sectional study of adolescents (n 121 OW/OB and n 102 NW) aged 12-14 years, attending a secondary school in Nonthaburi province, Thailand. Socio-demographic data were obtained from participants' parents using a questionnaire. Participants recorded their intakes for 3 non-consecutive days, using a prospective food record.

RESULTS

Compared with NW adolescents, OW/OB adolescents consumed more total protein and animal protein after adjustment for energy intake (both p = 0.047). OW/OB adolescents whose mothers were less educated consumed more total iron and available iron after adjustment for energy intake, compared with their OW/OB peers whose mothers were more educated (p = 0.045 and p = 0.040). NW adolescents with more highly educated mothers had higher absolute and energy-adjusted fibre intakes (both p = 0.047). However, NW adolescents of mothers with a high-intermediate level of education consumed less calcium, after adjustment for energy intake (p = 0.028).

CONCLUSIONS

OW/OB adolescents with less educated mothers had higher energy-adjusted intakes of iron and available iron. Dietary differences in OW/OB adolescents relative to maternal education, and other socioeconomic indicators, should be explored in a nationally representative data set.

The Effect of Breakfast Type on Total Daily Energy Intake and Body Mass Index Among Thai School Children

The study investigated the association between breakfast types consumed, daily energy intake, and body mass index for age Z-score (BAZ). Cross-sectional data from 1258 children aged 7 to 12.9 years were analyzed for breakfast type, nutrient intakes, BAZ, and proportion of overweight or obesity. Analysis of covariance was used to compare energy and nutrient intakes, BAZ, and proportion of overweight/obese children between breakfast groups. Only 19% of children had adequate energy intake from breakfast. Those consuming snacks had a significantly lower BAZ (Z = -0.73), with 5% of them being overweight/obese. Those consuming beverages and desserts had the lowest total daily energy intake (1314 kcal) and lowest protein intake (8.4 g). The results suggest that breakfast type is associated with daily energy intake and BAZ. Most breakfasts are not adequate. School-based nutrition education programs involving families, teachers, and health professionals can contribute to improve this situation.