Association of vitamin A deficiency with early childhood stunting in Uganda: A population-based cross-sectional study

Prevalence and Determinants of Stunting-Anemia and Wasting-Anemia Comorbidities and Micronutrient Deficiencies in Children Under 5 in the Least-Developed Countries: A Systematic Review and Meta-analysis

CONTEXT

Despite shifting from addressing isolated forms of malnutrition to recognizing its multifaceted nature, evidence on the prevalence and determinants of micronutrient deficiencies, and their coexistence with undernutrition in children under 5, remains insufficient, unsystematic, and incohesive.

OBJECTIVE

The aim of this systematic review and meta-analysis was to assess the prevalence and determinants of stunting-anemia and wasting-anemia comorbidities and micronutrient deficiencies in children under 5 in the least-developed countries (LDCs).

DATA SOURCES

Electronic searches took place from January 15, 2023, to February 14, 2024, across multiple databases, including PubMed, Embase, Web of Science, SCOPUS, African Index Medicus (AIM), World Health Organization's Institutional Repository for Information Sharing (IRIS), and African Journals Online. The search spanned the years 2000 to 2024, yet it yielded eligible full-text English research articles from only 2005 to 2021 conducted in LDCs. Studies lacking quantitative data on malnutrition types and their determinants were excluded.

DATA EXTRACTION

Two independent authors assessed articles for bias and quality using Hoy et al's 10-item scale and Newcastle-Ottawa Scale (NOS) criteria. Prevalence and other details were extracted using a Joanna Briggs Institute Excel template. Authors extracted adjusted odds ratios (aORs) for determinant factors such as sex and vitamin A and iron supplementation.

DATA ANALYSIS

The search yielded 6248 articles from 46 LDCs. Sixty-nine articles, with a total sample size of 181 605, met inclusion criteria for the final meta-analysis. Vitamin A deficiency affected 16.32% of children, and iodine deficiency affected 43.41% of children. The pooled prevalence of wasting-anemia and stunting-anemia comorbidity was 5.44% and 19.47%, respectively. Stunting was associated with vitamin A deficiency (aOR: 1.54; 95% CI: 1.01-2.37), and not taking vitamin A supplementation was associated with iron-deficiency anemia (aOR: 1.37; 95% CI: 1.21-1.55).

CONCLUSION

A significant proportion of children under 5 in LDCs experienced stunting-anemia and wasting-anemia comorbidities and micronutrient deficiencies. This study underscores the urgent need to address factors driving these burdens.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023409483.

Under-5 Malaria and Fever Morbidities as Correlates of Anaemia in Niger: A Heteroscedasticity-Consistent Ordered Probit Approach

Background: The relationship between malaria/other febrile infections and anaemia among under-5 children is a subject of significant policy relevance among African health policy makers. The international significance of addressing anaemia is prominently underscored in the third Sustainable Development Goal (SDG). This paper therefore analysed the effect of malaria/other febrile infections and other maternal and child's demographic variables on the prevalence of anaemia in Niger. Methods: We utilized the under-5 children's module of the Malaria Indicator Survey (MIS) for 2021, which was collected from women of reproductive age (15-49) in selected households. The data were analysed with heteroscedasticity-consistent ordered probit regression model. Results: The results showed that 73.73% of the children was anaemic, while malaria and other febrile infections were present in 14.00% and 33.87%, respectively. Anaemia was highest in the Tillaberi and Dosso regions, where 84.12% and 79.12% of the children were anaemic. The ordered probit regression revealed that anaemia was promoted by malaria, other febrile infections, being a male child, second of multiple birth, and birth order, while wealth index, age, urban residence, and access to newspaper and television reduced it. Conclusions: Anaemia remains a major public health problem among under-5 children in Niger. A comprehensive healthcare intervention to address the problem should consider regional, sectoral, and gender differences in the incidences, with drastic efforts towards prevention of malaria and other fever-inducing illnesses. In addition, interventions to promote households' economic status, reduce maternal fertility, and facilitate preventive practices through nutrition enhancement and health-related media programs hold some promise.

Prediction of undernutrition and identification of its influencing predictors among under-five children in Bangladesh using explainable machine learning algorithms

BACKGROUND AND OBJECTIVES

Child undernutrition is a leading global health concern, especially in low and middle-income developing countries, including Bangladesh. Thus, the objectives of this study are to develop an appropriate model for predicting the risk of undernutrition and identify its influencing predictors among under-five children in Bangladesh using explainable machine learning algorithms.

MATERIALS AND METHODS

This study used the latest nationally representative cross-sectional Bangladesh demographic health survey (BDHS), 2017-18 data. The Boruta technique was implemented to identify the important predictors of undernutrition, and logistic regression, artificial neural network, random forest, and extreme gradient boosting (XGB) were adopted to predict undernutrition (stunting, wasting, and underweight) risk. The models' performance was evaluated through accuracy and area under the curve (AUC). Additionally, SHapley Additive exPlanations (SHAP) were employed to illustrate the influencing predictors of undernutrition.

RESULTS

The XGB-based model outperformed the other models, with the accuracy and AUC respectively 81.73% and 0.802 for stunting, 76.15% and 0.622 for wasting, and 79.13% and 0.712 for underweight. Moreover, the SHAP method demonstrated that the father's education, wealth, mother's education, BMI, birth interval, vitamin A, watching television, toilet facility, residence, and water source are the influential predictors of stunting. While, BMI, mother education, and BCG of wasting; and father education, wealth, mother education, BMI, birth interval, toilet facility, breastfeeding, birth order, and residence of underweight.

CONCLUSION

The proposed integrating framework will be supportive as a method for selecting important predictors and predicting children who are at high risk of stunting, wasting, and underweight in Bangladesh.

The current status of genetic biofortification in alleviating malnutrition in Africa

Africa is a continent where undernutrition and micronutrient deficiencies are common and malnutrition is a major problem. Genetic biofortification (GB) offers a promising way to combat malnutrition. But little is still known about how widely used GB is in Africa today. This review explores the status, achievements, and challenges of GB on the continent today. It draws attention to the potential for enhanced nutritional results from biofortified crops that are enhanced with vital elements like zinc, iron, and vitamin A. Biofortification has a demonstrable positive effect on health and wellness, as evidenced by success stories from several African nations. However, obstacles like a lack of farmer awareness, difficulty obtaining biofortified seeds, and complicated regulations make adoption difficult. Research and collaboration advances hold the potential for increasing GB's effectiveness. This study offers guidance for the future and calls for coordinated efforts to implement GB programs to achieve a well-nourished Africa.

The influence of multivitamins on neurological and growth disorders: a cross-sectional study

Background

While vitamin deficiencies can pose serious health consequences for the body, excessive intake of vitamins can also lead to health risks. However, there is limited data about the impact of multivitamins on neurological and growth disorders. This study aimed to investigate the relationship between multivitamins and neurological and growth disorders.

Methods

A cross-sectional study was conducted with 16,921 subjects who visited the Children's Hospital of Nanjing Medical University from 2019 to 2021. The subjects were categorized into two groups based on their health status including 9,368 cases (4,484 with neurological disorders and 4,884 with growth disorders) and 7,553 healthy controls. Statistical tests including the T-test, Wilcoxon Rank Sum test, and Chi-Square test were employed to compare the groups, and logistic regression and Weighted Quantile Sum (WQS) regression were used to identify associations.

Results

In the adjusted logistic regression, serum 25 hydroxyvitamin D [25(OH)D], vitamin B2, and vitamin B9 were associated with decreasing risks of neurological disorders, whereas vitamin A, vitamin B1, and vitamin B12 were associated with increasing risks of neurological disorders. Nevertheless, vitamin A and vitamin B2 were associated with increasing risks of growth disorders. In the WQS model, nine multivitamins were positively associated with risks of neurological disorders, and Vitamins D and C were weighted the most. In addition, the inverse association but not statistically significant was observed between multivitamins and growth disorders, particularly growth retardation revealed a negative association, and some individual growth disorders revealed positive associations including obesity and malnutrition.

Conclusion

In general, the study observed that multivitamins may be associated with neurological and growth disorders either positive or negative depending on the type of disorder.

Birth weight mediates the association of maternal undernutrition with child undernutrition prevalence in West Africa

BACKGROUND

Maternal nutritional status before and during pregnancy is an important determinant of foetal health. In West Africa, maternal and child undernutrition remains a major public health problem and it is important to establish the mechanistic pathway linking the two disorders to help address the problem. We therefore assessed the mediating role of low birth weight (LBW) in the relationship of maternal undernutrition with child undernutrition in West Africa.

METHODS

We included recent (2010-2019) DHS data from thirteen West African countries. Poisson regression model with robust standard errors was used to assess the relationship between maternal undernutrition (body mass index and anaemia) and child undernutrition (stunting, wasting, underweight, and anaemia). Structural equation modelling was used to conduct the mediation analysis.

RESULTS

Prevalence of stunting, wasting, underweight, and anaemia among under-five children in West Africa was found to be 32.4%, 8.1%, 20.1%, and 71.5%, respectively. We found children of underweight mothers to be more likely to be undernourished (stunted, wasted, and underweight) and anaemic compared to children of normal-weight mothers. Also, children of anaemic mothers were more likely to be stunted and anaemic but not wasted compared with children of non-anaemic mothers. LBW mediated the observed relationships between maternal BMI and childhood stunting (22.6%), and maternal anaemia and childhood stunting (24.9%), wasting (11.7), and anaemia (6.6%).

CONCLUSION

We found maternal undernutrition to be associated with child undernutrition in West Africa with LBW noted to be a mediator of the observed relationship. We recommend that, to address the child undernutrition problem in West Africa, governments and policymakers must integrate measures to address the burden of LBW.

Overnutrition is a risk factor for iron, but not for zinc or vitamin A deficiency in children and young people: a systematic review and meta-analysis

INTRODUCTION

Traditionally associated with undernutrition, increasing evidence suggests micronutrient deficiencies can coexist with overnutrition. Therefore, this work aimed to systematically review the associations between iron, zinc and vitamin A (VA) status and weight status (both underweight and overweight) in children and young people.

METHODS

Ovid Medline, Ovid Embase, Scopus and Cochrane databases were systematically searched for observational studies assessing micronutrient status (blood, serum or plasma levels of iron, zinc or VA biomarkers) and weight status (body mass index or other anthropometric measurement) in humans under 25 years of any ethnicity and gender. Risk of bias assessment was conducted using the American Dietetic Association Quality Criteria Checklist. Where possible, random effects restricted maximum likelihood meta-analyses were performed.

RESULTS

After screening, 83 observational studies involving 190 443 participants from 44 countries were identified, with many studies having reported on more than one micronutrient and/or weight status indicator. Iron was the most investigated micronutrient, with 46, 28 and 27 studies reporting data for iron, zinc and VA status, respectively. Synthesising 16 records of OR from seven eligible studies, overnutrition (overweight and obesity) increased odds of iron deficiency (ID) (OR (95% CI): 1.51 (1.20 to 1.82), p<0.0001, I2=40.7%). Odds appeared to be higher for children living with obesity (1.88 (1.33 to 2.43), p<0.0001, I2=20.6%) in comparison to those with overweight (1.31 (0.98 to 1.64), p<0.0001, I2=40.5%), although between group differences were not significant (p=0.08).

CONCLUSIONS

Overnutrition is associated with increased risk of ID, but not zinc or VA deficiencies, with an inverted U-shaped relationship observed between iron status and bodyweight. Our results highlight significant heterogeneity in the reporting of micronutrient biomarkers and how deficiencies were defined. Inflammation status was rarely adequately accounted for, and the burden of ID may well be under-recognised, particularly in children and young people living with overnutrition.

PROSPERO REGISTRATION NUMBER

CRD42020221523.

Clinical vitamin A deficiency among preschool aged children in southwest Ethiopia

Background

The clinical manifestations of vitamin A deficiency (VAD) involve night blindness, bitot's spots, corneal xerosis, and corneal scars. It is the most important cause of preventable childhood blindness among children and causes morbidity and mortality. Even though Ethiopia implemented high-potency vitamin A supplements, the occurrence of VAD remains significant. This study was to identify determinants of clinical VAD among preschool-aged children (PSC) in southwest Ethiopia.

Method

A community-based survey was conducted among 411 randomly selected PSCs. A pretested and structured questionnaire coupled with clinical observation for signs of vitamin A deficiency by a trained ophthalmologist was used to collect the data. An anthropometric measurement of height was taken and analyzed using WHO Anthro to calculate Z-scores for each index. The public health significance of VAD was declared after comparison with international references. A bi-variable and multi-variable logistic analysis was done. We reported the adjusted odds ratio (AOR), 95% confidence interval, and p-value.

Result

A total of 411 children were screened for clinical VAD, and the overall prevalence was 2.2% (95% CI: 1.5-2.5). Of which, night blindness affects 1.2%, bitot's spots affects 0.7%, and corneal xerosis affects 0.2%, indicating a major public health problem compared to the international reference. The odds of clinical VAD were 81% lower among children who received vitamin A supplementation (VAS; AOR = 0.19, 95% CI: 0.04-0.92). On the other hand, PSC of mothers who had attended ANC visits were 89% less likely to develop clinical VAD (AOR = 0.11, 95% CI: 0.02-0.53). In addition, the study revealed that the odds of developing clinical VAD are 82% lower among PSC aged 36 to 47 months (AOR = 0.18; 95% CI: 0.03-0.97).

Conclusion

The prevalence of clinical VAD among PSC is a public health problem and is associated with ANC visits, VAS status, and the age of the child, which could be used to target interventions to further reduce existing VAD. Further studies using reliable dietary intake and biomarker data could further depict the burden of subclinical VAD.

Safely managed sanitation practice and childhood stunting among under five years old children in Myanmar

In 2020, 149 million children under the age of five were estimated to be stunted globally. Around half of deaths among children under 5 years of age are related to under-nutrition. Objective of this study is to determine the association between safely managed sanitation and childhood stunting among under-five years old children in Myanmar. This cross-sectional analytical study was conducted in 16 townships across three regions and five states in Myanmar. Multiple logistic regressions analysis was performed to determine the associations. This study found that 327 (27.09%) under-five children were stunted among a total of 1207 children in Myanmar. Children with unsafely managed sanitation were 2.88 times more likely to be stunting compared with children who access to safely managed sanitation services (AOR = 2.88, 95% CI: 2.16 to 3.85; p-value <0.01). Other associated factors for childhood stunting were needs 1-15 minutes for water collection (AOR = 2.07, 95% CI: 1.46 to 2.94; p-value <0.01), 15-60 minutes for water collection times (AOR = 1.55, 95% CI: 1.08 to 2.23; p-value 0.02), improper waste water disposal (AOR = 1.99, 95% CI: 1.47 to 2.70; p-value <0.01), boys children (AOR = 4.49, 95% CI: 3.30 to 6.12; p-value <0.01), did not take vitamin A supplements(AOR = 1.64, 95% CI: 1.22 to 2.20; p-value <0.01), mothers height shorter than 153.4cm (AOR = 1.94, 95% CI: 1.45 to 2.58; p-value <0.01), and the lower minimal diet diversity (AOR = 1.47, 95% CI: 1.08 to 2.01; p-value 0.02). More access to safely managed sanitation facilities, technical sharing for proper waste water disposal, promoting household water supply system, health promotion for children's diet eating pattern, and regular support for Vitamin A supplementation are critical to reduce childhood stunting among children under the age of five in Myanmar.

Relationships of deworming drug consumption and animal protein intake with stunting

By the end of 2022, the nationwide incidence of stunting remained high, including in Lampung Province, where it was 15.8%, above the target of 14% to be achieved by 2024. Since 2019, stunting has become a national priority due to suspected factors such as low nutrition intake, especially from animal protein sources, high rates of worm infections, and low compliance of under-fives in consuming deworming drugs. Therefore, this research aimed to analyze the relationship between deworming consumption, adequacy of animal protein intake, and stunting incidence in children aged 12-59 months in Bandar Lampung in 2022. This research used an analytic survey with a cross-sectional approach to analyze the relationship between deworming consumption, adequacy of animal protein intake, and stunting in under-fives at two priority stunting handling neighbourhoods in Bandar Lampung, namely Way Gubak and Karang Maritim. The sample consisted of 262 under fives and their mothers who visited the integrated health post in the selected neighbourhoods from November to December 2022, and the data obtained were analyzed using logistic regression. The results revealed a relationship between the consumption of an deworming and varying animal protein consumption with stunting incidence. This indicated a need to promote the importance of consuming deworming and adequate consumption of animal protein with variation to prevent stunting in children in Bandar Lampung.

Micronutrients and Nutrition Status of School-Aged Children in Indonesia

Micronutrient deficiencies (MNDs) in school-aged children are still a major health problem in Indonesia. This study was designed to examine the status of micronutrients and their relationship to the nutritional status of children aged 5-12 years since an up-to-date database on the micronutrient status of children aged 5-12 years is needed. Data from the 2018 Indonesian Basic Health Research (Riskesdas) were used in this study, with 2456 subjects for analysis. Micronutrient analysis was carried out, including iron status (ferritin, C reactive protein (CRP)), levels of zinc, vitamin D, calcium, and vitamin A (retinol) in school-aged children (5-12 years). The ELISA measurement was applied to measure CRP, ferritin, and vitamin D. Zinc levels were analysed with atomic absorbance spectroscopy (AAS). Moreover, high-performance liquid chromatography (HPLC) was applied to calculate vitamin A. In addition, stunting and thinness data were also obtained from the Riskesdas study. The results showed that the prevalence of stunting and thinness in school-aged children was 11.4% and 9.2%, respectively, showing that the stunting prevalence in the city was lower than in the village (4.5% vs. 6.9%, P = 0.000, respectively). In addition, the prevalence of MNDs in Indonesian children was 13.4%, 19.7%, 4.2%, 3%, and 12.7% for ferritin, zinc, calcium, vitamin A, and vitamin D, respectively. The mean serum level of vitamin A and zinc was significantly lower in stunted children compared to normal school children (P = 0.010 and P = 0.014). The serum concentration of vitamin D was significantly lower in overweight children compared to thin and normal children (P = 0.000). Serum values of ferritin, zinc, and vitamin A were significantly higher in overweight children compared to thin and normal children (P = 0.000). A poor correlation was observed between the z-score of height-for-age (HAZ) and the levels of zinc (r = 0.089, P = 0.000), vitamin A (r = 0.105, P = 0.000), and vitamin D (-0.073, P = 0.000). In addition, very weak correlations between z-scores of body mass index-for-age (BAZ) and the serum concentrations of ferritin (0.091, P = 0.000), zinc (r = 0.115, P = 0.000), vitamin A (r = 0.137, P = 0.000), and vitamin D (r = -0.112, P = 0.000) were also seen. In conclusion, school-aged children in Indonesia experienced stunting, thinness, and micronutrient deficiency. Furthermore, stunting and thinness were also related to micronutrient deficiencies.

Correlates of Iron, Cobalamin, Folate, and Vitamin A Status among Stunted Children: A Cross-Sectional Study in Uganda

Micronutrient deficiencies and stunting are prevalent. We assessed correlates of iron, cobalamin, folate, and vitamin A biomarkers in a cross-sectional study of stunted children aged 12-59 months in eastern Uganda. The biomarkers measured were serum ferritin (S-FE), soluble transferrin receptor (S-TfR), retinol binding protein (S-RBP), plasma cobalamin (P-Cob), methylmalonic acid (P-MMA), and folate (P-Fol). Using linear regression, we assessed socio-demography, stunting severity, malaria rapid test, and inflammation as correlates of micronutrient biomarkers. Of the 750 children, the mean (SD) age was 32.0 (11.7) months, and 45% were girls. Iron stores were depleted (inflammation-corrected S-FE < 12 µg/L) in 43%, and 62% had tissue iron deficiency (S-TfR > 8.3 mg/L). P-Cob was low (<148 pmol/L) and marginal (148-221 pmol/L) in 3% and 20%, and 16% had high P-MMA (>0.75 µmol/L). Inflammation-corrected S-RBP was low (<0.7 µmol/L) in 21% and P-Fol (<14 nmol/L) in 1%. Age 24-59 months was associated with higher S-FE and P-Fol and lower S-TfR. Breastfeeding beyond infancy was associated with lower iron status and cobalamin status, and malaria was associated with lower cobalamin status and tissue iron deficiency (higher S-TfR) despite iron sequestration in stores (higher S-FE). In conclusion, stunted children have iron, cobalamin, and vitamin A deficiencies. Interventions addressing stunting should target co-existing micronutrient deficiencies.

Micronutrient and Nutritional Status of HIV-Exposed and HIV-Unexposed Malawian Infants in the First Year of Life: Assessment of Ferritin, Vitamin A, and D Status and Its Association with Growth

Breastfed Malawian infants from Human Immunodeficiency Virus (HIV)-uninfected and HIV-infected women who received antiretroviral therapy were followed until 12 months of age, allowing us to evaluate plasma levels of ferritin, vitamin A (as retinol-binding protein, RBP), and vitamin D (25(OH)D) at six months, as well as nutritional status and growth between six and 12 months. Ferritin and RBP levels were adjusted for inflammation. The study included 88 infants, 63 of whom were part of a recent cohort (2019-2021) that included 49 HIV-exposed but uninfected (HEU) and 14 HIV-unexposed and uninfected (HUU) infants, as well as 25 infants (all HEU) from an earlier cohort (2008-2011). No differences were observed between HEU and HUU infants regarding micronutrient levels, anthropometric indexes, growth, and rates of stunting, being underweight, or wasting. HEU infants from the earlier cohort, when compared to more recent HEU infants, had significantly worse anthropometric measures at six months and inferior growth between six and twelve months. Overall, ferritin deficiency involved 68.6% of infants, while vitamin A and vitamin D deficiency involved 8% and 1.2% of infants, respectively. Micronutrient deficiencies were not associated with HIV exposure, cohort, stunting, being underweight, or wasting. At six months, stunting, being underweight, and wasting involved 25.0%, 2.7% and 2.8% of infants, respectively, with no differences related to HIV exposure. Ferritin deficiency at six months was associated with inferior subsequent growth. In this small observational study conducted in Malawian infants, no major nutritional gap was observed between HIV-exposed and HIV-unexposed infants, though the study highlighted specific nutritional deficiencies that deserve attention. High rates of stunting and ferritin deficiency were observed in the first year of life in Malawian infants, irrespective of maternal HIV status; a significant association between ferritin deficiency and worse subsequent growth was found. Vitamin A and vitamin D deficiencies were much less frequent. Based on the data observed, nutritional interventions should give priority to the correction of ferritin deficiency and chronic undernutrition.

High prevalence of malnutrition and vitamin A deficiency among schoolchildren of rural areas in Malaysia using a multi-school assessment approach

Childhood malnutrition is known as a public health concern globally. The present study aims to assess the anthropometry and blood biochemical status of rural primary schoolchildren in Malaysia. A total of 776 children (7-11 years old) from ten rural primary schools from five states were included in this study. Nutritional outcomes were assessed based on sex, age group and school categories among the children (median age: 9 years (P25:8, P75:10)). The overall prevalence of malnutrition was 53·4 %. Vitamin A deficiency (VAD) was recorded at 20·6 and 39·8 % based on retinol and retinol-binding protein (RBP) levels, respectively. Anaemia, iron deficiency (ID), iron-deficiency anaemia (IDA) and elevated inflammation were found at 14·9, 17·9, 9·1 and 11·5 %, respectively. Malnutrition, VAD, anaemia, ID, IDA and elevated inflammation were more prevalent among Orang Asli (OA) schoolchildren compared with Non-Orang Asli schoolchildren. Higher occurrences of VAD and anaemia were also found among children aged <10 years. Retinol, RBP, α-carotene, ferritin and haemoglobin levels were lower among undernourished children. Besides, overweight/obese children exhibited a higher level of high-sensitivity C-reactive protein. Multivariate analysis demonstrated that OA school children (adjusted OR (AOR): 6·1; 95 % CI 4·1, 9·0) and IDA (AOR: 3·6; 95 % CI 1·9, 6·6) were associated with stunting among this population. The present study revealed that malnutrition, micronutrient deficiencies and anaemia are prevalent among rural primary schoolchildren in Malaysia, especially those from OA schools and younger age children (<10 years). Hence, more appropriate and targeted measures are needed to improve the nutritional status of these children.

Prevalence and risk predictors of childhood stunting in Bangladesh

BACKGROUND

The child nutritional status of a country is a potential indicator of socioeconomic development. Child malnutrition is still the leading cause of severe health and welfare problems across Bangladesh. The most prevalent form of child malnutrition, stunting, is a serious public health issue in many low and middle-income countries. This study aimed to investigate the heterogeneous effect of some child, maternal, household, and health-related predictors, along with the quantiles of the conditional distribution of Z-score for height-for-age (HAZ) of under five children in Bangladesh.

METHODS AND MATERIALS

In this study, a sample of 8,321 children under five years of age was studied from BDHS-2017-18. The chi-square test was mainly used to identify the significant predictors of the HAZ score and sequential quantile regression was used to estimate the heterogeneous effect of the significant predictors at different quantiles of the conditional HAZ distribution.

RESULTS

The findings revealed that female children were significantly shorter than their male counterparts except at the 75th quantile. It was also discovered that children aged 7-47 months were disadvantaged, but children aged 48-59 months were advantaged in terms of height over children aged 6 months or younger. Moreover, children with a higher birth order had significantly lower HAZ scores than 1st birth order children. In addition, home delivery, the duration of breastfeeding, and the BCG vaccine and vitamin A received status were found to have varied significant negative associations with the HAZ score. As well, seven or fewer antenatal care visits was negatively associated with the HAZ score, but more than seven antenatal care visits was positively associated with the HAZ score. Additionally, children who lived in urban areas and whose mothers were over 18 years and either normal weight or overweight had a significant height advantage. Furthermore, parental secondary or higher education had a significant positive but varied effect across the conditional HAZ distribution, except for the mother's education, at the 50th quantile. Children from wealthier families were also around 0.30 standard deviations (SD) taller than those from the poorest families. Religion also had a significant relationship with the conditional HAZ distribution in favor of non-Muslim children.

CONCLUSIONS

To enhance children's nutritional levels, intervention measures should be designed considering the estimated heterogeneous effect of the risk factors. This would accelerate the progress towards achieving the targets of Sustainable Development Goals (SDGs) related to child and maternal health in Bangladesh by 2030.

Vitamin A deficiency and associated risk factors in children aged 12-59 months living in poorest municipalities in the South Region of Brazil

OBJECTIVE

To estimate the prevalence of vitamin A deficiency (VAD) in children and associated risk factors.

DESIGN

Analysis of data from a cross-sectional multicentre study performed in the primary care units of the municipalities from January to June 2015. The children's legal guardians answered a socio-economic questionnaire, and the children's blood samples were obtained by venipuncture. Plasma retinol was determined by HPLC. Plasma retinol values of <0·70 μmol/l were considered VDA. Poisson multiple regression with robust variance was used. Values of P < 0·05 were considered significant. The data were analysed in the SPSS software, 21.0.

SETTING

Forty-eight poorest municipalities in the South Region of Brazil.

PARTICIPANTS

Children (n 1503) aged 12-59 months.

RESULTS

The prevalence of VAD in the sample was 1·9 % (95 % CI (0·5, 6·8)). The following risk factors were associated with the outcome in the final explanatory model: family received Bolsa Familia program benefits (PR = 3·19; 95 % CI (1·69, 6·02)), child was not being breastfed (PR = 5·22; 95 % CI (1·68, 16·18)) and stunting (PR = 4·75; 95 % CI (2·10, 10·73)).

CONCLUSIONS

VAD did not represent a public health problem for children living in socio-economically vulnerable municipalities in the South Region of Brazil, suggesting a new panorama of this nutritional deficiency even in regions of low socio-economic conditions in these three states. Thus, in view of the current nutritional transition scenario, it is necessary to continuously monitor and improve public policies related to vitamin A supplementation in the country.

Assessing the potential determinants of national vitamin A supplementation among children aged 6-35 months in Ethiopia: further analysis of the 2019 Ethiopian Mini Demographic and Health Survey

Background

Vitamin A is a nutrient that is required in a small amount for normal visual system function, growth and development, epithelia’s cellular integrity, immune function, and reproduction. Vitamin A has a significant and clinically important effect since it has been associated with a reduction in all-cause and diarrhea mortality. The aim of this study was to determine factors associated with national vitamin A supplementation among children aged 6–35 months.

Method

The data for this study was extracted from the 2019 Ethiopian Mini Demographic and Health Survey. A total weighted sample of 2242 women with children aged 6–35 months was included in the study. The analysis was performed using Stata version 14.2 software. Applying sampling weight for descriptive statistics and complex sample design for inferential statistics, a manual backward stepwise elimination approach was applied. Finally, statistical significance declared at the level of p value < 0.05.

Result

The overall coverage of vitamin A supplementation among children aged 6–35 months for the survey included was 44.4 95% CI (40.15, 48.74). In the multivariable analysis, mothers who had four or more antenatal visits [AOR = 2.02 (95% CI: 1.34, 3.04)] were two times more likely to receive vitamin A capsules for their children than mothers who had no antenatal visits. Children from middle-wealth quintiles had higher odds of receiving vitamin A capsules in comparison to children from the poorest wealth quintile [AOR = 1.77 (95% CI: 1.14, 2.73)]. Older children had higher odds of receiving vitamin A capsules than the youngest ones. Other factors that were associated with vitamin A supplementation were mode of delivery and region.

Conclusion

The coverage of vitamin A supplementation in Ethiopia remains low and it is strongly associated with antenatal visit, household wealth index and age of child. Expanding maternal health services like antenatal care visits should be prioritized.

Child stunting starts in utero: Growth trajectories and determinants in Ugandan infants

Childhood stunting remains a public health burden worldwide. Although many studies have examined early life and in-utero risk factors; most have been observational and have used analytic techniques that make inferences limited to population means, thereby obscuring important within-group variations. This study addressed that important gap. Using data from a birth cohort of Ugandan infants (n = 4528), we applied group-based trajectory modelling to assess diverse patterns of growth among children from birth to 1-year old. A multinomial regression model was conducted to understand the relationship between risk factors and observed patterns across groups. We found that the onset of stunting occurred before birth and followed four distinct growth patterns: chronically stunted (Group 1), recovery (Group 2), borderline stunted (Group 3) and normal (Group 4). The average length-for-age z-score (LAZ) at birth was -2.6, -3.9, -0.6 and 0.5 for Groups 1-4, respectively. Although both Groups 1 and 2 were stunted at birth, stunting persisted in Group 1 while children in Group 2 recovered by the fourth month. Group 3 exhibited mild stunting while Group 4 was normal. Wasting and underweight were observed in all groups, with the highest prevalence of underweight in Group 1. Wasting gradually increased among children born already stunted (Groups 1 and 2). This showed the importance of distinguishing children by their growth patterns rather than aggregating them and only comparing population averages against global growth standards. The design of nutrition interventions should consider the differential factors and potential for growth gains relative to different risks within each group.

The Role of Nutrients and MCV on Stunting: A Case Study on Indonesian Early Teenagers

BACKGROUND: Many teenagers experience many nutritional problems, including anemia and stunting. The correlation between energy intake, protein, iron, and stunting with MCV levels in stunting adolescents in Jatinangor is not yet known. AIM: This study aims to analyze the correlation of energy intake, protein, iron, and stunting and MCV levels in stunting adolescents in Jatinangor. METHODS: This study was conducted with a cross-sectional design involving early adolescents aged 10-14 years in Jatinangor District as many as 41 people. Analysis of MCV levels was done by taking blood through veins. Stunting data were obtained based on WHO criteria with a value of z-score TB / U<- 2 SD and nutritional intake data including energy, protein, and iron obtained through 24-hour recall. To determine the intake of nutrients is done by interviewing with the method of 24 hours recall and FFQ. The data were analyzed with the Pearson Correlation Test. RESULTS: The correlation between energy intake and MCV levels was p=0.022 (r=0.356). Furthermore, the correlation of protein intake and MCV levels was p=0.257, and iron intake with MCV levels was p=0.301. Eventually, the stunting correlation test to MCV levels was p=0.006 (r=0.419). CONCLUSIONS: This study concludes that there is a correlation between energy intake and the value of the z-score TB / U index with MCV levels. There is no significant correlation between protein intake and iron intake with MCV levels in stunting adolescents in Jatinangor. There is a correlation between MCV and stunting levels, and there is no correlation between nutrient intake and stunting.

Dietary Diversity of Women across Agricultural Seasons in the Kapchorwa District, Uganda: Results from a Cohort Study

Small-holder farm households in developing countries mainly depend on rain-fed agriculture activities, thus seasonality affects eating habits and contributes to micronutrient deficiencies. This study assessed women’s dietary diversity score (WDDS) across three agricultural seasons in the Kapchorwa District, Uganda. In each season, 445 women with under five-year-old children from small-holder farm households were interviewed on socio-demographic characteristics as well as dietary practices between May 2016 and January 2017. Linear regression models estimated differences in WDDS across seasons. The mean WDDS at the lean, harvest and post-harvest seasons was 4.33 ± 1.21, 4.63 ± 1.30 and 4.36 ± 1.21, respectively. Mean WDDS was higher in urban regions across all seasons. Women in urban regions generated more income through off-farm activities, had better access to markets and consumed significantly more ‘meat, poultry and fish’ (p < 0.001), dairy products (p < 0.05), ‘vitamin A-rich fruits and vegetables’ (p < 0.001) and ‘other vegetables’ (p < 0.001) during the lean season, whilst rural women ate more dark green leafy vegetables (p < 0.001) during the same period. Poorer households in the rural setting were more likely to be affected by seasonally limited food availability and accessibility. Hence, strengthening the linkages between market participation, agricultural activities, improved food storage and preservation techniques and dietary intake is recommended.

Estimated effect of vitamin A supplementation on anaemia and anthropometric failure of Indian children

BACKGROUND

India has an unacceptably high burden of vitamin A deficiency (VAD) among children aged 6-59 months. To mitigate VAD and its adverse effects on child health, the Indian government runs a nationwide vitamin A supplementation (VAS) programme. However, the effect of VAS in reducing child morbidity and mortality remains inconclusive and has been debated globally. In this paper, we estimate the effect of VAS on two indicators of child nutrition-anaemia (categorized into any anaemia, and mild/moderate anaemia) and anthropometric failure (categorized into stunting, wasting, and underweight) among children aged 6-59 months.

METHODS

Using the nationally representative 2015-2016 National Family Health Survey data set from India, we set up a quasi-experimental study design and estimated household and mother fixed-effects of VAS on select types of child anaemia and anthropometric failure.

RESULTS

Findings from both the household fixed-effects and mother fixed-effects analysis showed that VAS does not influence any types of childhood anaemia and anthropometric failure in India. We discussed the findings considering existing literature and possible limitations of the study.

CONCLUSIONS

The infirm effect of Vitamin A on anaemia and anthropometric failure is probably indicative of targeted VAS intervention, as opposed to a universal VAS programme.

IMPACT

Effects of vitamin A supplementation (VAS) in treating child morbidity and mortality remain inconclusive, which calls for further rigorous studies. This study set up a quasi-experimental research design and estimated the null effect of VAS on child anaemia and childhood anthropometric failure. While the cautious interpretation of findings is urged, this study reliably supports targeted intervention of VAS, instead of the universal VAS programme. The use of nationally representative data and robust research protocol are the primary strengths of this study.

Neonatal stunting and early childhood caries: A mini-review

The nutritional status of pregnant women greatly determines their newborn outcome. Deficiencies of several micronutrients are associated with stunting in early childhood, affecting health into adulthood. However, apart from the systemic disease that has been a concern so far, fetal undernutrition can also be associated with dental caries in a child's early life, especially since the primary teeth begin to form during the mother's gestation period. The important thing to underline regarding the intrauterine formation of primary teeth is especially in terms of enamel formation. One of the causes of developmental enamel defects that will contribute to the emergence of early childhood caries is the malnutrition of the pregnant mother. This mini-review aims to understand the linkage mechanism behind neonatal stunting to early childhood caries. This concept is expected to generate further research to help prevent both growth stunting and early childhood caries. In addition, with some evidence-based research, the importance of the first dental visit can be further promoted.

Rural-urban determinants of vitamin a deficiency among under 5 children in Bangladesh: Evidence from National Survey 2017-18

Background

Vitamin A supplementation reduces child morbidity, mortality, and blindness of people, especially in developing countries like Bangladesh. This study explores significant determinants of vitamin A deficiency among preschool children in rural and urban areas of Bangladesh.

Methods

The data set was extracted from a nationally representative survey based on a cross-sectional study, the BDHS-2017-18. The base survey was conducted using a two-stage stratified sample of households. A sample of 8364 (urban 2911, rural 5453) children under-5 years old was analyzed using bivariate and multivariate statistical techniques.

Results

Results have demonstrated that 73.9 and 73.2% of children have had a vitamin A supplementation from urban and rural areas, respectively. Logistic regression analysis showed that parents’ education plays a vital role in consuming vitamin A supplements in urban and rural areas. Children whose mothers have secondary (OR: 1.17, CI: 0.76–1.81) and higher (OR: 1.21, CI: 0.72–2.04) education were more likely to consume vitamin A supplementation than children whose mothers were illiterate in urban areas. However, in rural areas, children whose mothers have secondary education were about 24% and higher education with 60% more likely to consume vitamin A supplementation than children whose mothers were illiterate. Child’s age, regional variation and wealth index also contributing factors for vitamin A deficiency in Bangladesh.

Conclusions

These findings indicated that the consumption of vitamin A does not cover the target of sustainable development goals. Thus special national and community level efforts are required to ensure the coverage of the national vitamin A program is increased adequately to the most vulnerable groups of children in Bangladesh.

Vitamin D in the Covid-19 era: a review with recommendations from a G.I.O.S.E.G. expert panel

Vitamin D (VITD) is a key hormone for bone health and has relevant extra-skeletal effects that might play a role in the prevention and treatment of COronaVIrus Disease 19 (COVID-19). Literature regarding this scenario is voluminous but controversial. Glucocorticoid Induced Osteoporosis Skeletal Endocrinology Group (G.I.O.S.E.G) has been present in the scientific debate about the use of VITD and has regularly interfaced national regulatory agencies to ensure appropriateness of its employment. Given the current pandemic and the questions on COVID-19 and VITD, G.I.O.S.E.G. appointed an expert panel to advise how to consider this issue best. The results of these deliberations are reported in the current recommendation paper.

High Prevalence of Stunting and Anaemia Is Associated with Multiple Micronutrient Deficiencies in School Children of Small-Scale Farmers from Chamwino and Kilosa Districts, Tanzania

Inadequate macro- and micronutrient nutrition and its consequences, such as anaemia, iron and vitamin deficiency, and growth retardation, could particularly affect children of small-scale farmers. In the present cross-sectional study, 666 school children aged 5-10 years from villages of Chamwino and Kilosa districts were studied for associations between nutritional and micronutrient status and dietary intake. The overall prevalence of stunting, underweight, and overweight was 28.1, 14.4, and 5%, while that of anaemia and deficiency of iron (ID), vitamin A (VAD), and zinc (ZnD) was 42.9, 29.3, 24.9, and 26.4%, respectively. Dietary recalls (24h) revealed that, except of iron (74%), only small proportions of children reached the recommended daily micronutrient intakes: 4% for zinc, 19% for vitamin A, and 14-46% for B vitamins. Stunting was highly associated with wasting in both districts and with VAD in Chamwino. Anaemia was predicted by ID, VAD, and ZnD in Chamwino and by elevated infection markers, C-reactive protein (CRP) and α-1 glycoprotein (AGP), in Kilosa. Overall, elevated CRP and/or AGP increased the risk while higher serum carotenoids indicating a diet of more fruit and vegetables reduced the risk of VAD. The significantly lower prevalence of anaemia and ID in Chamwino was related to higher iron and vitamin A intake and the consumption of mainly bulrush millet with dark green leafy vegetables compared to maize or rice with legumes in Kilosa. Nutrition and hygiene education integrated with home and school garden programmes could reduce the multiple burdens of anaemia; micronutrient deficiencies and infections; and, in the long term, the prevalence of stunting.

Global, regional and national epidemiology and prevalence of child stunting, wasting and underweight in low- and middle-income countries, 2006-2018

In 2016, undernutrition, as manifested in childhood stunting, wasting, and underweight were estimated to cause over 1.0 million deaths, 3.9% of years of life lost, and 3.8% of disability-adjusted life years globally. The objective of this study is to estimate the prevalence of undernutrition in low- and middle-income countries (LMICs) using the 2006-2018 cross-sectional nationally representative demographic and health surveys (DHS) data and to explore the sources of regional variations. Anthropometric measurements of children 0-59 months of age from DHS in 62 LMICs worldwide were used. Complete information was available for height-for-age (n = 624,734), weight-for-height (n = 625,230) and weight-for-age (n = 626,130). Random-effects models were fit to estimate the pooled prevalence of stunting, wasting, and underweight. Sources of heterogeneity in the prevalence estimates were explored through subgroup meta-analyses and meta-regression using generalized linear mixed-effects models. Human development index (a country-specific composite index based on life expectancy, literacy, access to education and per capita gross domestic product) and the United Nations region were explored as potential sources of variation in undernutrition. The overall prevalence was 29.1% (95% CI 26.7%, 31.6%) for stunting, 6.3% (95% CI 4.6%, 8.2%) for wasting, and 13.7% (95% CI 10.9%, 16.9%) for underweight. Subgroup analyses suggested that Western Africa, Southern Asia, and Southeastern Asia had a substantially higher estimated prevalence of undernutrition than global average estimates. In multivariable meta-regression, a combination of human development index and United Nations region (a proxy for geographical variation) explained 54%, 56%, and 66% of the variation in stunting, wasting, and underweight prevalence, respectively. Our findings demonstrate that regional, subregional, and country disparities in undernutrition remain, and the residual gaps to close towards achieving the second sustainable development goal-ending undernutrition by 2030.

Hidden Hunger of Vitamin E among Healthy College Students: A Cross- Sectional Study

BACKGROUND

College students may have a risk of fat-soluble vitamin deficiencies due to unhealthy dietary habits, especially for vitamin A and E. They are important members of the human antioxidant network; deficiencies of these vitamins may increase the risk of many critical diseases.

OBJECTIVE

The current study was undertaken to determine the status of vitamin A and E in college students.

METHODS

Healthy college students were recruited, and fasting blood samples of them were collected and used for determining serum levels of retinol and α-tocopherol by the HPLC method.

RESULTS

We found that there was no vitamin A deficiency in college students. However, vitamin E deficiency existed in 34.5% of college students, especially in males. All the students had no vitamin E adequacy. In addition, our findings showed that BMI was inversely associated with serum α-- tocopherol, but not serum retinol.

CONCLUSION

These results suggest that vitamin E deficiency in college students should be given more attention, and it is necessary to consider using vitamin E supplements.

Complementary Feeding: Pitfalls for Health Outcomes

The term complementary feeding is defined as the period in which a progressive reduction of breastfeeding or infant-formula feeding takes place, while the infant is gradually introduced to solid foods. It is a crucial time in the infant's life, not only because of the rapid changes in nutritional requirements and the consequent impact on infant growth and development, but also for a generation of lifelong flavor preferences and dietary habits that will influence mid and long-term health. There is an increasing body of evidence addressing the pivotal role of nutrition, especially during the early stages of life, and its link to the onset of chronic non-communicable diseases, such as obesity, hypertension, diabetes, and allergic diseases. It is clear that the way in which a child is introduced to complementary foods may have effects on the individual's entire life. The aim of this review is to discuss the effects of complementary feeding timing, composition, and mode on mid and long-term health outcomes, in the light of the current evidence. Furthermore, we suggest practical tips for a healthy approach to complementary feeding, aiming at a healthy future, and highlight gaps to be filled.

Village-level climate and weather variability, mediated by village-level crop yield, is associated with linear growth in children in Uganda

INTRODUCTION

To investigate total annual precipitation, precipitation anomaly and aridity index in relation to linear growth in children under 5 in Uganda and quantify the mediating role of crop yield.

METHODS

We analysed data of 5219 children under 5 years of age who participated in the 2016 Uganda Demographic and Health Survey. Annual crop yield in kilograms per hectare for 42 crops at a 0.1° (~10 km at the equator) spatial resolution square grid was obtained from the International Food Policy Research Institute. Normalised rainfall anomaly and total precipitation were derived from the African Rainfall Estimation Algorithm Version 2 product. Linear regression models were used to associate total annual precipitation and anomalies with height-for-age z-scores and to explore the mediating role of crop yield qualitatively. The intervening effects were quantitatively estimated by causal mediation models.

RESULTS

Twenty-nine per cent of children were stunted (95% CI 28% to 31%). After adjusting for major covariates, higher total annual precipitation was significantly associated with increasing height-for-age z-scores. At the mean, an increase of 1 standard deviation in local annual rainfall was associated with a 0.07-point higher z-score. Aridity index and precipitation anomaly were not associated with height-for-age z scores in altitude-adjusted models. Crop yields of nuts, seeds, cereals and pulses were significant mediating factors. For instance, 38% of the association between total annual precipitation with height-for-age z-scores can be attributed to the yield of sesame seeds.

CONCLUSIONS

Higher total annual precipitation at the village-level was significantly associated with higher height-for-age z-scores among children in Uganda. This association can be partially explained by higher crop yield, especially from seeds and nuts. This study suggests that more attention should be paid to villages with lower annual rainfall amounts to improve water availability for agriculture.