Unhealthy weight among young children in the Middle East and North African region

OBJECTIVE

To understand early-life growth in the Middle East and North Africa (MENA) region, and how it has changed over time, we estimated the prevalence of wasting and overweight at ages under 5 years.

DESIGN

Cross-sectional data from twenty-nine Demographic and Health Surveys with direct anthropometric data and parent-reported demographic information were examined. The study utilised the WHO Child Growth Standards to classify overweight (weight-for-height z-score ≥ 2 sd above the median), wasting (weight-for-height z-score ≤ 2 sd below the median) and unhealthy weight defined as either wasting or overweight.

SETTING

Nationally representative for nine of the MENA countries (Armenia, Azerbaijan, Egypt, Jordan, Mauritania, Morocco, Tunisia, Turkey and Yemen).

PARTICIPANTS

Children under age 5 from nine MENA countries between 1987 and 2016 (n 155 961).

RESULTS

Across the region, at the most recent time point, between 7·3 and 23·6 % of children experienced unhealthy weight (Jordan - 7·3 %, Egypt -23·6 %); 1·7 and 16·6 % had wasting (Turkey, Yemen) and 2·0 and 15·0 % had overweight (Yemen, Egypt). Overweight was more common than wasting in all countries except Yemen and Mauritania. Between 1987 and 2016, the prevalence of unhealthy weight in the region increased (10·0-18·4 %) due to increases in both wasting and overweight. Boys had a higher prevalence of unhealthy weight than girls.

CONCLUSION

Undernutrition continues to be a problem in some countries in the MENA region, and overnutrition is emerging as a health concern in many countries in the region. Countries in the region must advance programmes that reduce undernutrition while not overlooking or inadvertently promoting overnutrition.

Cultural adaptations and methodological innovations to group model building for the systems actions to reduce malnutrition in all its forms in Southeast Asian countries and China (SYSTAM CHINA-SEACS International Consortium) project

BACKGROUND

Group Model Building (GMB) is a participatory system dynamics method increasingly used to address complex public health issues like obesity. GMB represents a set of well-defined steps to engage key stakeholders to identify shared drivers and solutions of a given problem. However, GMB has not yet been applied specifically to develop multi-duty interventions that address multiple inter-related issues such as malnutrition in all its forms (MIAIF). Moreover, a recent systematic review of empirical applications of a systems approach to developing obesity interventions found no published work from non-western, low- and middle-income countries (LMICs). In this paper we describe adaptations and innovations to a common GMB process to co-develop systemic MIAIF interventions with Chinese decision-makers.

METHODS

We developed, piloted and implemented multiple cultural adaptations and two methodological innovations to the commonly used GMB process in Fang Cheng Gang city, China. We included formal, ceremonial and policy maker engagement events before and between GMB workshops, and incorporated culturally tailored arrangements during participant recruitment (officials of the same seniority level joined the same workshop) and workshop activities (e.g., use of individual scoring activities and hand boards). We made changes to the commonly used GMB activities which enabled mapping of shared drivers of multiple health issues (in our case MIAIF) in a single causal loop diagram. We developed and used a 'hybrid' GMB format combining online and in person facilitation to reduce travel and associated climate impact.

RESULTS

Our innovative GMB process led to high engagement and support from decision-makers representing diverse governmental departments across the whole food systems. We co-identified and prioritised systemic drivers and intervention themes of MIAIF. The city government established an official Local Action Group for long-term, inter-departmental implementation, monitoring and evaluation of the co-developed interventions. The 'hybrid' GMB format enabled great interactions while reducing international travel and mitigating limitations of fully online GMB process.

CONCLUSIONS

Cultural and methodological adaptations to the common GMB process for an Asian LMIC setting were successful. The 'hybrid' GMB format is feasible, cost-effective, and more environmentally friendly. These cultural adaptations could be considered for other Asian settings and beyond to address inter-related, complex issues such as MIAIF.

Dietary Diversity and Undernutrition in Children Aged 6-23 Months in Sub-Saharan Africa

Dietary diversity plays a major role in the health status of children. However, evidence on its crucial role on children's health status remains inconclusive in sub-Saharan Africa (SSA). In this study, we examined the association between dietary diversity and undernutrition among children aged 6-23 months in SSA. We pooled data from the most recent Demographic and Health Surveys of 32 countries in SSA from 2010 to 2020. A sample of 48,968 mother-child pairs of children within the ages of 6-23 months and mothers aged 15-49 years were included in this study. Multilevel logistic regression analysis was carried out to examine the association between dietary diversity and stunting, wasting, and underweight. The results were presented as crude odds ratios (cOR) and adjusted odds ratios (aOR) with their 95% confidence intervals. Statistical significance was set at p < 0.05. The overall prevalence of minimum dietary diversity was 25.1%, with South Africa recording the highest prevalence (43.9%) and Burkina Faso recording the lowest prevalence (5.6%). The highest prevalence of stunting was recorded by Burundi (51.8%) while the lowest prevalence was found in Ghana (13.6%), with an overall regional prevalence of 28.6%. For wasting, prevalence from all countries was found to be 9.4%. South Africa recorded the lowest prevalence of wasting (2.1%) while Niger recorded the highest prevalence (27.3%). Lastly, the prevalence of underweight ranged from 5.3% in South Africa to 41.8% in Niger, with an all-country prevalence of 16.4%. Children who had adequate minimum dietary diversity had 12% less likelihood of being stunted (aOR = 0.88, 95% CI = 0.83, 0.94), compared to those who had inadequate minimum dietary diversity. Having an adequate minimum dietary diversity significantly lowered the risk of underweight among children by 17% (aOR = 0.83, 95% CI = 0.77, 0.91). Having an adequate minimum dietary diversity was associated with 13% reduced odds of wasting among children (aOR = 0.87, 95% CI = 0.78, 0.97), compared to those who had inadequate minimum dietary diversity. This study highlights the significant association between minimum dietary diversity and stunting, wasting, and underweight among 6-23 month-old children in SSA. There is an urgent need for additional nutrition-specific interventions and strengthening of existing interventions aimed at improving infant and young child feeding practices, including complementary feeding practices among children aged 6-23 months in the 32 countries in SSA. Such interventions should focus more on countries where the prevalence of adequate minimum dietary diversity was low and undernutrition was high.

Prevalence and Determinants of the Co-Occurrence of Overweight or Obesity and Micronutrient Deficiencies among Adults in the Philippines: Results from a National Representative Survey

The double burden of malnutrition (DBM) affects many low- and middle-income countries. However, few studies have examined DBM at the individual level, or undernutrition and overnutrition co-occurring within the same person. This study aims to investigate the prevalence and determinants of DBM among adults in the Philippines. Data from the 2013 National Nutrition Survey were used. The sample size in the analysis was 17,010 adults aged ≥20 years old, after excluding pregnant and lactating women. DBM was defined as the co-occurrence of overweight/obesity and anemia (definition #1), overweight/obesity and anemia or vitamin A deficiency (definition #2), and overweight/obesity and anemia or vitamin A deficiency or iodine insufficiency (definition #3). Anthropometric measurements and biochemical markers were used for DBM assessment. Data were analyzed using descriptive statistics, the chi-square test, and logistic regression by R software. Results showed that definition #3 is the predominant type of DBM (7.0%) in the general population, whereas the prevalence of DBM has increased to 23.7% in overweight/obese persons. Sex, age, educational attainment, marital status, household size, wealth quintile, and smoking status were the determinants of DBM. This study revealed that Filipino adults experience malnutrition critically and must be addressed through food and nutrition interventions.

Ethnic Differences in Loneliness, Depression, and Malnutrition Among Older Adults During COVID-19 Quarantine

BACKGROUND

Depression in older adults may result from a variety of reasons such as loneliness feelings and malnutrition.

OBJECTIVE

To examine the direct and indirect effect of loneliness feelings on depressive symptoms, mediated by malnutrition, among older adults from different cultures during the Coronavirus disease 2019 (Covid-19) pandemic quarantine.

METHOD

A convenience sample of 101 Arabs and 100 Jewish older adults aged 65 and over was interviewed. Using bootstrapping, we tested the strength and significance of the conditional indirect effect of malnutrition (mediator) on the relationship between loneliness feelings and depressive symptoms.

RESULTS

The relationship between loneliness feelings and depressive symptoms was mediated by malnutrition and Arab older adults reported a higher level than Jewish older adults of loneliness, depression, and malnutrition during the Covid-19 pandemic quarantine.

CONCLUSIONS AND IMPLICATIONS

To reduce loneliness feelings, depressive symptoms, and malnutrition in times of crisis like the Covid-19 pandemic, it is essential to develop new communication methods for and with older adults in general, with particular attention paid to ethnic differences, that will be effective in reducing loneliness and in promoting nutrition intervention. Possible solutions include new social network technologies for reducing loneliness, with continued reliance on phone communication for combined intervention that includes psychological support accompanied by instructions for a healthy lifestyle and malnutrition prevention.

Prevalence of obesity and diabetes in the socioeconomic transition of rural Mayas of Yucatan from 1962 to 2000

Background: The Mayas of the State of Yucatan in Mexico are the only aboriginal group with obesity and diabetes data before 1997. Objective: To analyze socioeconomic trends associated with the increase in obesity and diabetes seen in rural Yucatan from 1962 to 2000. Methods: Body weight, height and venous Fasting Blood Glucose (FBG) were measured in 263 rural Maya adults participating in a 2000 nutrition survey. Results: Diabetes (FBG > 125 mg/dL) and obesity (BMI ≥ 30 kg/m²) were 10.6% and 35.7%, respectively. These results contrast with those of a 1962 survey where diabetic prevalence was 2.3% and 0% in women and men respectively, with widespread adult pellagra and malnutrition. An important socioeconomic transition that took place in Yucatan during this lapse appeared to be associated to the obesity and diabetes increase. Conclusions: Rural Yucatan evolved from malnutrition conditions to high prevalence of obesity and diabetes in less than 40 years. This change was associated with the transition from an agroindustry-based economy, characterized by high-energy expenditure and low protein intake, to lower energy requirements of a Government-subsidized economy with larger food supply.

Caution is Needed in Interpreting Hemoglobin A1c Levels in the Muslim Bedouin Population of Southern Israel

The Bedouins living in southern Israel are a Muslim-Arab population that is transitioning from a nomadic lifestyle to life in permanent settlements. The population has unique characteristics that could affect hemoglobin A1c (HbA1c) measurements. The objective of this study was to describe the socio-demographic and unique morbidity characteristics of this community and their effect on HbA1c measurements. Consanguinity, especially among cousins in the Bedouin population, results in a high prevalence of autosomal recessive genetic diseases such as thalassemia (underestimate of HbA1c), hemoglobinopathies (underestimate and overestimate), Gilbert's disease, and glucose-6-phosphate dehydrogenase deficiency, an X-linked disorder, which can cause hyperbilirubinemia with an overestimate of HbA1c. Furthermore, nutritional deficiencies, autosomal recessive diseases, high birth rates, parasitic infections, and poverty can all cause high rates of anemia (iron and vitamin B12 deficiencies) that can raise HbA1c levels. Congenital dyserythropoietic anemia is found among Bedouin tribes in the Negev region and can lead to an underestimation of HbA1c levels. Pregnancy can also affect HbA1c levels. Medical teams working in the Bedouin community and in other Muslim populations with similar morbidity characteristics throughout the world should identify patients with medical conditions that can affect HbA1c measurements and be aware of possible measurement alternatives such as fructosamine and glycated albumin.

Open defecation explains differences in nutritional status between Bengali and tribal children in the Chittagong Hill Tracts of Bangladesh

OBJECTIVE

We describe differences in linear growth as measured by height-for-age z-score (HAZ) between children from Bengali and tribal populations in the Chittagong Hill Tracts of Bangladesh and examine factors associated with HAZ in both groups.

DESIGN

We used nutritional surveillance data collected in Bangladesh from 2003 to 2006 to analyze HAZ among 12,006 children aged 6-23 months and conducted multivariate linear regression and Blinder-Oaxaca decomposition to quantify the relative contribution of independent variables to differences in HAZ between Bengali and tribal children.

RESULTS

Mean HAZ was stable for Bengali children (-1.88 in 2003 to -1.90 in 2006) but improved for tribal children (-1.87 in 2003 to -1.68 in 2006). The difference between groups was significant across the study period (p = 0.008). Among Bengali children, HAZ was positively associated with father's schooling (β = 0.221; 95% CI: 0.079-0.363). Among tribal children, HAZ was positively associated with consumption of animal source foods (β = 0.073; 95% CI: 0.051-0.096) and goat ownership (β = 0.240; 95% CI: 0.025-0.454). Results of a likelihood ratio test indicated that distance to a health center was inversely associated with HAZ among tribal children (p < 0.001). Blinder-Oaxaca decomposition demonstrated a difference in pooled coefficients between groups (p = 0.004), explained primarily by differences in coefficients for paternal education (p = 0.001) and village-level prevalence of open defecation (p = 0.004).

CONCLUSIONS

Different responses among Bengali and tribal children to village-level open defecation are an explanatory factor for the difference in HAZ between Bengali and tribal populations. Open defecation may also act a proxy for unmeasured factors such as household environmental conditions and food hygiene.

ABBREVIATIONS

Chittagong Hill Tracts (CHT); height-for-age z-scores (HAZ); Nutrition Surveillance Project (NSP); World Health Organization (WHO).

Acute Malnutrition and Anemia Among Rohingya Children in Kutupalong Camp, Bangladesh

This survey study assesses the health and nutritional status of Rohingya children aged 6 to 59 months in the Kutupalong refugee camp in Bangladesh.

Parental history of moderate to severe infantile malnutrition is associated with cognitive deficits in their adult offspring

OBJECTIVES

We compared the IQ and academic achievement of the young adult offspring of parents malnourished in infancy and those of a healthy control group in order to test the hypothesis that the offspring of previously malnourished individuals would show IQ and academic deficits that could be related to reduced parental socioeconomic status.

METHODS

We conducted a group comparison study based on a community sample in Barbados (Barbados Nutrition Study). Participants were adult children ≥16 years of age whose parents had been malnourished during the first year of life (n = 64; Mean age 19.3 years; 42% male) or whose parents were healthy community controls (n = 50; Mean age 19.7 years; 48% male). The primary outcome was estimated IQ (Wechsler Abbreviated Scale of Intelligence); a secondary outcome was academic achievement (Wide Range Achievement Test - Third Edition). Data were analyzed using PROC MIXED with and without adjusting for parental socioeconomic status (Hollingshead Index of Social Position).

RESULTS

IQ was reduced in the offspring of previously malnourished parents relative to the offspring of controls (9.8 point deficit; P < 0.01), but this difference was not explained by parental socioeconomic status or parental IQ. The magnitude of the group difference was smaller for basic academic skills and did not meet criteria for statistical significance.

DISCUSSION

The deleterious impact of infant malnutrition on cognitive function may be transmitted to the next generation; however, this intergenerational effect does not appear to be explained by the reduced socioeconomic status or IQ of the parent generation.

Program considerations for integration of nutrition and family planning: Beliefs around maternal diet and breastfeeding within the context of the nutrition transition in Egypt

In Egypt, rising maternal overweight and obesity is consistent with the transition to westernized diets and a growing reliance on energy-dense, low nutrient foods. Although the first 1,000 days of life are the focus of many programmes designed to prevent many forms of malnutrition, little attention has been paid to maternal dietary practices and weight gain during pregnancy. This study used in-depth interviews with pregnant women (N = 40), lactating women (N = 40), and nonlactating women (N = 40) to gain an understanding of behaviours, perceptions, and cultural beliefs in relation to maternal dietary intake during pregnancy, lactation, and nonlactation; weight gain during pregnancy; birth spacing; and family planning. Study findings reveal that food choice was driven by affordability, favoured foods, or foods considered appropriate for a specific life stage (pregnant, lactating, and nonlactating). Knowledge of weight gain during pregnancy is limited, especially with regards to excessive weight gain during pregnancy. Diet is often modified during lactation to support breast milk production, and a normal diet resumed when breastfeeding ceases. Within the context of breastfeeding, the lactational amenorrhea method provides an opportunity to improve exclusive breastfeeding practices, maternal diet during lactation, and the transition to other family planning methods by 6 months postpartum. Health care providers should discuss limiting maternal consumption of low nutrient foods such as junk foods, soda, and teas during pregnancy and postpartum. Dietary counselling should accompany information on appropriate weight gain during pregnancy and exercise to prevent excessive weight gain, in the context of the nutrition transition.

Nutritional status of preschool children attending kindergartens in Kosovo

BACKGROUND

There is very limited data on malnutrition of preschool children in Kosovo. The main objective of the study is to provide a nutritional status profile of preschool children attending kindergartens in Kosovo.

METHODS

Cross-sectional study of children aged 12-59 months (n = 352 children) and children aged 60-83 months (n = 134) enrolled in public and private kindergartens of Kosovo. Anthropometric measurements used for this study are weight and height of the preschoolers (12-83 months). A measuring board was used for measuring the length/height of children younger than 2 years, while digital weight and height scale Seca 763 was used for measuring of preschool children taller than 110 and Seca 213 was used for measuring the height for children who were shorter than 110 cm. Statistical analyses of underweight and overweight trends across sex and age groups as well as between children from public and private kindergartens were carried out. Qualitative variables were tested with a chi-square test. The differences between groups were assessed with a Student t test for normally distributed variables and a Mann-Whitney test for abnormally distributed numerical variables.

RESULTS

The mean z-scores for weight-for-age, height-for-age, weight-for-height, and BMI-for-age largely fell within 0.0 and 1.0. The percentage of stunted children is 3%, whereas child wasting is 1.9%. The overall percentage of obese children is 2.3%; furthermore, 8.9% are overweight and 27.3% have a possible risk of being overweight.

CONCLUSIONS

The incidence of children underweight is slightly decreasing. The prevalence of overweight and obese children in sample chosen is evident.

Partnering with women collectives for delivering essential women's nutrition interventions in tribal areas of eastern India: a scoping study

BACKGROUND

We examined the feasibility of engaging women collectives in delivering a package of women's nutrition messages/services as a funded stakeholder in three tribal-dominated districts of Odisha, Jharkhand and Chhattisgarh States, in eastern India. These districts have high prevalence of child stunting and poor government service outreach.

METHODS

Conducted between July 2014 and March 2015, an exploratory mix-methods design was adopted (review of coverage data and government reports, field interviews and focus group discussion with multiple stakeholders and intended communities) to assess coverage of women's nutrition services. A capacity assessment tool was developed to map all types of community collectives and assess their awareness, institutional and programme capacity as a funded stakeholder for delivering women's nutrition services/behaviour promotion.

RESULTS

Limited targeting of pre-pregnancy period, delays in first trimester registration of pregnant women, and low micronutrient supplementation supply and awareness issues emerged as key bottlenecks in improving women's nutrition in these districts. Amongst the 18 different types of community collectives mapped, Self Help Groups (SHGs) and their federations (tier 2 and tier 3), with total membership of over 650,000, emerged as the most promising community collective due to their vast network, governance structure, bank linkage, and regular interface. Nearly 400,000 (or 20% of women) in these districts can be reached through the mapped 31,919 SHGs. SHGs with organisational readiness for receiving and managing grants for income generation and community development activities varied from 41 to 94% across study districts. Stakeholders perceived that SHGs federations managing grants from government and be engaged for nutrition promotion and service delivery and SHG weekly meetings can serve as community interface for discussing/resolving local issues impeding access to services.

CONCLUSIONS

Women SHGs (with tier 2 and tier 3) can become direct grantees for strengthening coverage of women's nutrition interventions in these tribal districts/pockets, provided they are capacitated, supervised and given safe guards against exploitation and violence.

Meal frequency and dietary diversity feeding practices among children 6-23 months of age in Wolaita Sodo town, Southern Ethiopia

BACKGROUND

Child feeding practices are multidimensional, and they change rapidly within short age intervals. Suboptimal complementary feeding practices contribute to a rapid increase in the prevalence of undernutrition in children in the age of 6-23 months. Information on child feeding practices among urban resident is limited in Ethiopia. The aim was to measure minimum meal frequency and dietary diversity and associated factors among children 6-23 months of age in Wolaita Sodo, Ethiopia.

METHODS

A community-based cross-sectional study was carried out to select 623 mothers/caregivers with 6-23 months of children reside in Wolaita Sodo town using systematic sampling from March 02 to 20, 2015. An interviewer-administered questionnaire was used to gather information on socio-demographic, child feeding practices and health-related characteristics. Data were entered to Epi-Data version 3.02 and transported to SPSS version 21 for further analysis. Binary logistic regression was used to see the association between the outcome variables and explanatory variables, and multivariable logistic regression was performed to identify independent predictors of minimum dietary diversity and meal frequency.

RESULTS

The study revealed that the percentage of 6-23 months of children who meet the recommended level of minimum dietary diversity and meal frequency were 27.3 and 68.9%, respectively. Mothers/caregivers who were housewives and government employees feed their children more diversified foods as compared to mothers who were private workers. As compared to children 17-23 months of age, children in the age group of 6-8 and 9-11 months had better probability to meet minimum dietary diversity. Government-employed and illiterate mothers were less likely to feed their children to fulfil the minimum requirement of meal frequency. Children in the age of 9-11 months were also less likely to be fed frequently.

CONCLUSIONS

Even though the study showed better progress as compared to the national prevalence of complementary feeding practices, child feeding practices in the study area were inadequate and not achieving WHO infant and young child feeding recommendations. Strengthening the available strategies and creating new intervention measures to improve socioeconomic status, maternal literacy and occupation opportunity for better practices of child feedings are compulsory actions for the government and policymakers.

[Changing trend of children's malnutrition and anemia rate from 2009 to 2015 in Taicang City, Jiangsu Province]

OBJECTIVE

To analyze the changing trend of children's malnutrition and anemia rate in Taicang City, Jiangsu Province from 2009 to 2015.

METHODS

Data of medical examination on children under 3 was retrived from Electronic Health Care Records in Taicang, Jiangsu, and children's malnutrition and anemia rates were assessed based on WHO children's growth standard in 2006 and anemia diagnosis standard in 2001. The differences of children's malnutrition and anemia rates from 2009 to 2015 were analyzed based on the data. The Mantel-Haenszel Estimation Method was used to standardize themalnutrition rate and the anemia rate. Mantel-Haenszel Chi-square test was used to compare the differences of count data.

RESULTS

The average WAZ, HAZ and WHZ scores were 0. 51, 0. 23 and 0. 56, and the average rates of low weight, stunting, wasting, overweight and obesity were 0. 65%, 1. 54%, 0. 56%, 6. 37% and 1. 03%, respectively. The rates of low weight, wasting, overweight and obesity remained stable from 2009 to 2015. The overweight rate increased from 5. 84% in 2009 to 6. 99% in2012, and dropped to 6. 12% in 2015( MH χ~2= 5. 41, P < 0. 05). The boys had a higher malnutrition rate than the girls, and the migrant children had worse conditions in stunting, overweight and obesity than local children. The anemia rate in children under 3 declined from 24. 02% in 2009 to 9. 25% in 2015( Cochran-Armitage Z = 29. 41, P < 0. 05). The boys had a higher anemia rate than the girls, and the local children had a higher anemia rate than the migrant children.

CONCLUSION

The growth status of children under 3 in Taicang from 2009 to 2015 is better than the WHO reference standards. The overweight rates increase from 2009 to 2012 and decline from 2012 to 2015. The anemia rate in children decline from 2009 to 2015. This study indicates that controlling the high overweight rate and high anemia rate in young children under 3 are two predominating working directions in Taicang, Jiangsu.

Hospital malnutrition in Latin America: A systematic review

BACKGROUND

Disease-related malnutrition is a major public health issue in both industrialised and emerging countries. The reported prevalence in hospitalised adults ranges from 20% to 50%. Initial reports from emerging countries suggested a higher prevalence compared with other regions, with limited data on outcomes and costs.

METHODS

We performed a systematic literature search for articles on disease-related malnutrition in Latin American countries published between January 1995 and September 2014. Studies reporting data on the prevalence, clinical outcomes, or economic costs of malnutrition in an adult (≥18 years) inpatient population with a sample size of ≥30 subjects were eligible for inclusion. Methodological quality of the studies was assessed by two independent reviewers using published criteria.

RESULTS

We identified 1467 citations; of these, 66 studies including 29 ,474 patients in 12 Latin American countries met the criteria for inclusion. There was considerable variability in methodology and in the reported prevalence of disease-related malnutrition; however, prevalence was consistently in the range of 40%-60% at the time of admission, with several studies reporting an increase in prevalence with increasing duration of hospitalisation. Disease-related malnutrition was associated with an increase in infectious and non-infectious clinical complications, length of hospital stay, and costs.

CONCLUSION

Disease-related malnutrition is a highly prevalent condition that imposes a substantial health and economic burden on the countries of Latin America. Further research is necessary to characterise screening/assessment practices and identify evidence-based solutions to this persistent and costly public health issue.

Gender Disparities in the Prevalence of Undernutrition and the Higher Risk among the Young Women of Indian Tribes

BACKGROUND

High undernutrition is a grave concern in India. Marginalized populations like Indian tribes have been under the serious stress of such nutritional extreme. Women, in particular, are the worst sufferers. Gender-related comprehensive studies regarding the prevalence and risks of undernutrition among the tribes have not been properly pursued in India; the vulnerability of the young females has least been examined.

METHODS AND FINDINGS

We conducted a cross-sectional study during January 2011 to December 2013 among 1066 males and 1090 females (n = 2156) in the 20-60 years age group belonging to the nine major tribes; Santals, Oraons and Koras (West Bengal): Santals, Bhumijs and Bathudis (Odisha): Dhodias, Kuknas and Chaudharis (Gujarat). The undernutrition burden was estimated and such risks were analyzed for the women in comparison to the men. The overall undernutrition among the females was found to be 47.4% (95% CI 44.4-50.4) against 32.1% (95% CI 29.3-34.9) among males, indicating about a half of the female population undernourished. The odds of risks for underweight status among females were observed to be high in comparison to males with an odds of 1.9 (95% CI, 1.6-2.2; p≤0.001) for the overall undernutrition category, 1.7 (95% CI, 1.3-2.3; p≤0.001) for the mild undernutrition category, 1.3 (95% CI, 1.1-1.6; p≤0.01) for combined moderate and mild undernutrition category and 3.3 (95% CI at 2.3-4.6; p≤0.001) for severe undernutrition category. The young females were observed with a high prevalence of undernutrition along with increased risk. The 30-year mean BMI trend of the Indian population in comparison to the males, females, and overall tribal population places the tribal females at the highest risk.

CONCLUSION

Indian tribes are suffering from the higher prevalence of undernutrition by further highlighting a high gender bias. The health and empowerment of adolescent and young tribal girls needs additional focus. Overall, no remarkable control on undernutrition has been achieved among Indian tribes despite various efforts.

Differences in Medical and Life-style Risk Factors for Malnutrition in Limited-Resource Older Adults in a Rural U.S. State: A Descriptive Study

OBJECTIVES

Medical and life-style factors are associated with malnutrition in older adults. This study assessed the presence of these risk factors in limited-resource, community-dwelling older adults to inform the development of a nutrition education interventions.

DESIGN

Quantitative descriptive study.

SETTING

A total of 24 randomly selected congregate nutrition sites (where limited-resource older adults can receive one hot meal/day, five days/week) in the rural state of South Carolina, USA.

PARTICIPANTS

Data were collected from 477 older adults (of the 407 who reported race, 219 were African American and 171 were White).

MEASUREMENTS

Extension Educators who work for the Cooperative Extension Service (a formalized educational outreach system associated with some U.S. universities) read aloud a 27-item instrument designed to assess risk factors for malnutrition. Response frequencies were tabulated and chi-square tests were performed using SAS 9.3.

RESULTS

More African Americans reported having a chronic illness or condition (81.2 vs. 68.3%; p=0.003), eating alone (66.2 vs. 53.6%; p=0.012), having a refrigerator that sometimes did not keep food cold (31.8 vs. 8.4%; p<0.0001), and sometimes not having enough money to buy food (38.9 vs. 18.5%; p<0.0001) compared to White older adults.

CONCLUSION

Rural older adults who attend congregate nutrition sites, especially African Americans, could be at risk for malnutrition due to health status and food preparation-related factors. Evidence-based, tailored programs are needed to minimize malnutrition among limited-resource older adults living in rural areas in the U.S.

Triple Burden of Obesity, Undernutrition, and Cardiovascular Disease Risk among Indian Tribes

BACKGROUND

Socio-cultural transitions among individuals from vulnerable groups introduce epidemiological transition, with a concomitant increase in the prevalence of undernutrition, obesity, and cardiovascular disease risks. An accepted conventional wisdom exists for Indian tribes that they are undernourished and away from lifestyle-related diseases. However, the extent of this triple burden affecting them is unknown. In this study, we assessed this triple burden among the 9 major tribes of India.

METHODS AND FINDINGS

During January 2011 to December 2013, we conducted a cross-sectional study among 1066 men and 1090 women constituting a total of 2156 adults belonging to the 9 major tribal groups: Santals, Oraons, and Koras (West Bengal); Santals, Bhumijs, and Bathudis (Odisha); and Dhodias, Kuknas, and Chaudharis (Gujarat) to estimate the prevalence of the triple burden (undernutrition, overweight or obesity, and hypertension). A high prevalence of undernutrition and hypertension was observed among the Koras (51.9%and 10.6%, respectively), Bathudis (51.3% and 12.1%, respectively), and Oraons (49.6% and 16.5%, respectively). However, the prevalence of overweight and hypertension among the Bhumijs (17.7% and 14.7%, respectively), Dhodias (23.8% and 12.9%, respectively), Kuknas (15.8% and 11.3%, respectively), and Santals of West Bengal (12.2% and 11.8%, respectively) and Odisha (15% and 9.6%, respectively) was most alarming. The prevalence of overweight or obesity among the women was 10.9% and 1.5%, respectively, with 14.0% hypertensive women. The prevalence of overweight and obesity among the men was 14.8% and 1.7%, respectively, with 9.2% hypertensive men. Undernutrition was highly prevalent among men and women. However, data from the past 30 years on systolic blood pressure (SBP) and body mass index (BMI) revealed that the studied tribes were at a higher risk than the general Indian population. In addition, a vast gender disparity with relation to the disease and risk prevalence was observed.

CONCLUSION

The alarming trend of an increasing prevalence of overweight/obesity, undernutrition, and hypertension is observed among indigenous populations of India, emphasizing the incorporation of a specific health management policy.

Are there changes in the nutritional status of children of Oportunidades families in rural Chiapas, Mexico? A cohort prospective study

BACKGROUND

In Mexico, despite that the fact that several social programs have been implemented, chronic undernutrition is still a public health problem affecting 1.5 million children of <5 years. Chiapas ranks first in underweight and stunting at national level with a stunting prevalence of 31.4 % whereas for its rural population is 44.2 %. The purpose of this paper is to determine if the nutritional status of a cohort of children living in poor rural communities under Oportunidades has changed. We were interested in assessing the nutrition evolution of the children who were initially diagnosed as stunted and of those who were diagnosed as normal. Oportunidades is an anti-poverty program of the Mexican government consisting mainly in monetary transfers to the families living in alimentary poverty.

METHODS

A 9-year cohort prospective study was conducted with nutritional evaluations of 222 children. Anthropometric indices were constructed from measurements of weight, height, and age of the children whose nutritional status was classified following WHO standards.

RESULTS

The results showed that although these children were Oportunidades beneficiaries for 9 years and their families improved their living conditions, children still had a high prevalence of stunting (40.1 %) and 69.6 % had not recovered yet. Children who were initially diagnosed with normal nutritional status and became stunted 2 years later had a higher risk (relative risk (RR) 5.69, 2.95-10.96) of continuing stunted at school age and adolescence.

CONCLUSIONS

Oportunidades has not impacted, as expected, the nutritional status of the study population. These findings pose the question: Why has not the nutritional status of children improved, although the living conditions of their families have significantly improved? This might be the result of an adaptation process achieved through a decrease of growth velocity. It is important to make efforts to watch the growth of the children during their first 3 years of age, to focus on improving the diet of women at fertile age and pay special attention to environmental conditions to break the vicious cycle of malnutrition.

[Study on malnutrition status among Wa ethnicity children and adolescents in Lingcang prefecture, Yunnan province]

OBJECTIVE

To analyze the malnutrition status among children and adolescents of Wa ethnicity in Lincang prefecture, Yunnan province from 2005 to 2014, and to provide evidence for the improvement of the situation.

METHODS

From 2005 to 2014, children and adolescents aged 7 to 18, from 19 primary and secondary schools in Cangyuan county of Lincang prefecture, Yunnan province, were chosen, using the multistage-stratified-random cluster sampling method, to receive physic examination. WHO-2006 standard was used. Situation related to the rate of growth retardation and malnutrition among students was analyzed, from 2005 to 2014. Data was from the National Student Physical Health Research Project. From 2000 to 2014, trends on nutrition development among these students were also studied.

RESULTS

The rates related to growth retardation among 7-18 years-old Wa boys in 2005, 2010 and 2014 were 45.61%, 52.36% and 35.85%, with the rates of thinness as 1.44%, 0.76% and 1.36% , respectively. Rates on malnutrition were 52.35% , 56.01% and 41.13% , respectively. Rates related to growth retardation among 7-18 years-old Wa girls were 42.03%, 47.41% and 33.06%, respectively, with rates of thinness as 0.91%, 0.68% and 0.83%, respectively. The rates on malnutrition were 46.13%, 49.77% and 35.56%, respectively. From year 2005 to 2014, spurt on height growth of boys and girls were among the 13-14 years-old and 9-10 years-old, respectively. Girls were 4 years earlier, entering the sudden increase in the peak age than boys. Sex difference on height among the 18 years-old Wa youngsters were 11.99, 9.34 and 11.38 cm in 2005, 2010 and 2014, respectively.

CONCLUSION

Malnutrition status of retardation on growth among Wa children and adolescents remained quite serious.

High risk of malnutrition associated with depressive symptoms in older South Africans living in KwaZulu-Natal, South Africa: a cross-sectional survey

BACKGROUND

Malnutrition contributes to functional and cognitive decline in older adults, which results in decreased quality of life and loss of independence. This study aimed to identify determinants of nutritional risk among community-dwelling adults in KwaZulu-Natal, South Africa.

METHODS

A cross-sectional survey was undertaken in 1008 subjects aged 60 years and over who were randomly selected by systematic sampling. Demographics, socioeconomic data and self-reported history of medical conditions were recorded. The Mini Nutritional Assessment-Short Form (MNA-SF) was used to screen for nutritional risk, and the Centre for Epidemiologic Studies Depression scale was administered to all subjects. Descriptive statistics and the Pearson chi-square and Kruskal-Wallis tests were used for statistical analysis. Logistic regression modelling determined predictors of nutritional risk.

RESULTS

Of the 984 participants (mean age = 68.8 ± 7.4 years; range 60-103 years) who completed the MNA-SF, 51% were classified as having a normal nutritional status, 43.4% at risk for malnutrition and 5.5% classified as malnourished. Men were more likely to be either at risk for malnutrition or be malnourished than women (p = 0.008), as were subjects with a monthly household income of ≤R1600 per month (~133 USD) (p = 0.003). In logistic regression models, depressed people were 2.803 (p < 0.001) times more likely to be at risk or be malnourished than those not depressed.

CONCLUSION

A high prevalence of risk of malnutrition was identified in older South Africans living in an urban area with poor infrastructure. Further investigations are warranted to determine whether the higher prevalence of depressive symptomatology in nutritionally at risk individuals is a determinant or a consequence of malnutrition, in order to develop targeted nutritional interventions in this age group.

Factors associated with nutrition risk in older Māori: a cross sectional study

AIM

To investigate factors associated with nutrition risk among older Māori.

METHOD

Māori aged 75-79 years living in the Northland and Bay of Plenty regions of New Zealand were assessed for nutrition risk using the validated screening tool 'Seniors in the Community: Risk Evaluation for Eating and Nutrition' (SCREENII). Demographic, physical and sociocultural data were collected.

RESULTS

Of the 67 participants, two thirds (63%) were identified to be at high-risk for malnutrition. More than half (56%) used te reo Māori (Māori language) for everyday conversation and those who rated language and culture as moderately important to wellbeing were at lower nutrition risk. Controlling for age, gender and living arrangements, participants who rated traditional foods as important, were able to access them, had a higher waist-to-hip ratio and an absence of depressive symptoms, were at lower nutrition risk.

CONCLUSIONS

Cultural factors associated with nutrition risk are related to an indigenous view of health. Participants with a higher waist-to-hip ratio were at lower nutrition risk and this may be a protective factor for older Māori. Interventions to improve the nutrition status of older Māori need to be based on a holistic Māori worldview and acknowledge the importance of traditional Māori foods.

Double-burden of malnutrition among the indigenous peoples (Orang Asli) of Peninsular Malaysia

BACKGROUND

Double-burden of malnutrition (DBM) is an emerging public health concern among the Orang Asli (indigenous peoples) of Peninsular Malaysia. This study aimed to identify the presence of DBM at the community and household levels in Orang Asli population and its associated demographic and socio-economic factors.

METHODS

This cross-sectional study was conducted in 11 Orang Asli villages surrounding the Krau Wildlife Reserve, Peninsular of Malaysia from October 2011 to January 2012. Of 438 households, a total of 981 adults and 304 children who met the study criteria agreed to participate. About 160 households were further selected with pairs of children aged 3-59 months and non-pregnant mothers aged 15-55 years. Demographic and socio-economic data were obtained using interviewer-administered questionnaire while weight and height were measured using standard procedures. Double-burden of malnutrition was defined as overweight/obese mother-underweight child (OWOBM/UWC), overweight/obese mother-stunted child (OWOBM/STC) or overweight/obese mother-underweight or/and stunted child (OWOBM/UWSTC). Binary logistic regression identified the demographic and socio-economic factors associated with double-burden households.

RESULTS

About 26 % of overweight and obese adults coexisting with high proportions of underweight (49%) and stunted (64%) children in these Orang Asli villages. There was a higher prevalence of households with OWOBM/UWSTC (20%) and OWOBM/STC (19.4%) than households with OWOBM/UWC (12.5%). Boys (P < 0.05), older age mothers (P < 0.05), mothers with higher education (P < 0.05) and households with income per capita less than USD 29.01 (RM 97.00) (P < 0.01) were associated with higher odds of OWOBM/STC. Jah Hut (P < 0.05) and higher number of children (P < 0.05) were significantly associated with lower odds of OWOBM/UWC.

CONCLUSIONS

The occurrence of double-burden of malnutrition in Orang Asli population deserves attention. Poverty reduction, access to quality diet and improved health and nutrition literacy are among strategies that could address the coexistence of DBM in this population.

Nutritional status of HIV-infected patients during the first year HAART in two West African cohorts

OBJECTIVE

To examine the association between nutritional markers at initiation and during follow up in two different cohorts of HIV-infected adults initiating highly active antiretroviral therapy (HAART) in West Africa.

METHODS

The ATARAO study was a one year prospective study carried in Mali. It consisted of a sample of consecutive patients initiating HAART in one of four participating centers during that period. Data were collected at time of treatment initiation (baseline) and every 3 months thereafter. The ANRS 1290 study followed Senegalese patients recruited in similar conditions. Bivariate analyses were used to identify nutritional and immunological covariates of malnutrition at baseline. Longitudinal trajectories of body mass index, hemoglobin and albumin, and their associated factors, were evaluated using mixed linear models.

RESULTS

In ATARAO, 250 participants were retained for analyses; of which, 36% had a BMI < 18.5 kg/m(2), nearly 60% were anemic and 47.4% hypoalbuminemic at time of treatment initiation. At baseline, low hemoglobin, hypoalbuminemia and low CD4 levels were associated with a BMI < 18.5 kg/m(2). Similarly, low BMI, low albumin and low CD4 counts were linked to anemia; while, hypoalbuminemia was associated with low hemoglobin levels and CD4 counts. In ANRS, out of the 372 participants retained for analyses, 31% had a low BMI and almost 70% were anemic. At baseline, low BMI was associated with low hemoglobin levels and CD4 counts, while anemia was associated with low CD4 counts and female sex. While treatment contributed to early gains in BMI, hemoglobin and albumin in the first 6 months of treatment, initial improvements plateaued or subsided thereafter. Despite HAART, malnutrition persisted in both cohorts after one year, especially in those who were anemic, hypoalbuminemic or had a low BMI at baseline.

CONCLUSION

In ATARAO and ANRS, malnutrition was common across all indicators (BMI, hemoglobin, albumin) and persisted despite treatment. Low BMI, anemia and hypoalbuminemia were associated with attrition, and with a deficient nutritional and immunological status at baseline, as well as during treatment. In spite of therapy, malnutrition is associated with negative clinical and treatment outcomes which suggests that HAART may not be sufficient to address co-existing nutritional deficiencies.

Early interruption of exclusive breastfeeding: results from the eight-country MAL-ED study

We report the infant feeding experiences in the first month of life for 2,053 infants participating in "Malnutrition and Enteric Infections: Consequences for Child Health and Development" (MAL-ED). Eight sites (in Bangladesh, India, Nepal, Pakistan, Brazil, Peru, South Africa, Tanzania), each followed a cohort of children from birth (by day 17), collecting detailed information on infant feeding practices, diet and illness episodes. Mothers were queried twice weekly regarding health status, breastfeeding and the introduction (or no) of non-breast milk liquids and foods. Here, our goal is to describe the early infant feeding practices in the cohort and evaluate factors associated with termination of exclusive breastfeeding in the first month of life. With data from enrollment to a visit at 28-33 days of life, we characterized exclusive, predominant or partial breastfeeding (using a median of 6-9 visits per child across the sites). Only 6 of 2,053 infants were never breastfed. By one month, the prevalences of exclusive breastfeeding were < 60% in 6 of 8 sites, and of partial breastfeeding (or no) were > 20% in 6 of 8 sites. Logistic regression revealed that prelacteal feeding (given to 4-63% of infants) increased the likelihood of partial breastfeeding (Odds Ratio (OR): 1.48 (95% confidence interval (CI): 1.04, 2.10), as did the withholding of colostrum (2-16% of infants) (OR: 1.63:1.01, 2.62), and being a first-time mother (OR: 1.38:1.10, 1.75). Our results reveal diversity across these sites, but an overall trend of early transition away from exclusive breastfeeding in the first month of life. Interventions which introduce or reinforce the WHO/UNICEF Ten Steps for Successful Breastfeeding are needed in these sites to improve breastfeeding initiation, to reinforce exclusive breastfeeding and delay introduction of non-breast milk foods and/or liquids.

Dietary Protein Intake in a Multi-ethnic Asian Population of Healthy Participants and Chronic Kidney Disease Patients

INTRODUCTION

Clinical practice guidelines recommend different levels of dietary protein intake in predialysis chronic kidney disease (CKD) patients. It is unknown how effectively these recommendations perform in a multi-ethnic Asian population, with varied cultural beliefs and diets. We assess the profi le of protein intake in a multi-ethnic Asian population, comparing healthy participants and CKD patients.

MATERIALS AND METHODS

We analysed the 24-hour urine collections of the Asian Kidney Disease Study (AKDS) and the Singapore Kidney Function Study (SKFS) to estimate total protein intake (TPI; g/day). We calculated ideal body weight (IDW; kg): 22.99 × height2 (m). Standard statistical tests were applied where appropriate, and linear regression was used to assess associations of continuous variables with protein intake.

RESULTS

There were 232 CKD patients and 103 healthy participants with 35.5% diabetics. The mean TPI in healthy participants was 58.89 ± 18.42 and the mean TPI in CKD patients was 53.64 ± 19.39. By US National Kidney Foundation (NKF) guidelines, 29/232 (12.5%) of CKD patients with measured glomerular filtration rate (GFR) <25 (in mL/min/1.73 m2) had a TPI-IDW of <0.6 g/kg/day. By Caring for Australasians with Renal Impairment (CARI) guidelines, 76.3% (177/232) of CKD patients had TPI-IDW >0.75g/kg/ day. By American Dietetic Association (ADA) guidelines, 34.7% (44/127) of CKD patients with GFR <50 had TPI-IDW between 0.6 to 0.8 g/kg/day. Only 1/6 non-diabetic CKD patients with GFR <20 had a protein intake of between 0.3 to 0.5 g/kg/day. A total of 21.9% (25/114) of diabetic CKD patients had protein intake between 0.8 to 0.9 g/kg/day.

CONCLUSION

On average, the protein intake of most CKD patients exceeds the recommendations of guidelines. Diabetic CKD patients should aim to have higher protein intakes.

'It was caused by the carelessness of the parents': cultural models of child malnutrition in southern Malawi

Parents' conceptions of child growth, health and malnutrition are culturally bound, making information about local understandings of malnutrition and its causes necessary for designing effective nutrition programmes. This study used ethnographic methods to elucidate cultural models of child care and malnutrition among the Yao of southern Malawi. Data were collected in six rural villages from 28 key informant interviews with village chiefs and traditional healers among others and 18 focus group discussions with parents and grandmothers of young children. For the Yao, lack of parental care is a key cause of poor child health and can lead to thinness (kunyililika) or swelling (kuimbangana). Parents are said to be careless if they are not attentive to the child's needs, are unable to provide adequate quality or quantity of food, or fail to follow sexual abstinence rules. Maintaining abstinence protects the family and failure to do so causes the transfer of 'heat' from a sexually active parent to a 'cold' child and results in child health problems, including signs and symptoms of malnutrition. These findings indicate that the Yao understanding of care is much broader than the concept of care during feeding described in the nutrition literature. In addition, the Yao note the importance of several key feeding practices supported by international agencies and understand the influence of illness on child nutritional status. These congruencies with the public health frame should be used together with information about the cultural context to design more socially and emotionally relevant care and nutrition programmes among the Yao.

Breakfast consumption is positively associated with nutrient adequacy in Canadian children and adolescents

Although breakfast is associated with more favourable nutrient intake profiles in children, limited data exist on the impact of breakfast on nutrient adequacy and the potential risk of excessive intakes. Accordingly, we assessed differences in nutrient intake and adequacy among breakfast non-consumers, consumers of breakfasts with ready-to-eat cereal (RTEC) and consumers of other types of breakfasts. We used cross-sectional data from 12,281 children and adolescents aged 4-18 years who took part in the nationally representative Canadian Community Health Survey, 2004. Mean nutrient intakes (obtained using a multiple-pass 24 h recall method) were compared among the breakfast groups using covariate-adjusted regression analysis. Usual nutrient intake distributions, generated using the National Cancer Institute method, were used to determine the prevalence of nutrient inadequacy or the potential risk of excessive intakes from food sources alone and from the combination of food plus supplements. Of these Canadian children, 10% were breakfast non-consumers, 33% were consumers of RTEC breakfasts and 57% were consumers of other types of breakfasts. Non-consumption of breakfast increased with age (4-8 years: 2%; 9-13 years: 9%; 14-18 years: 18%). Breakfast consumers had higher covariate-adjusted intakes of energy, many nutrients and fibre, and lower fat intakes. The prevalence of nutrient inadequacy for vitamin D, Ca, Fe and Mg (from food alone or from the combination of food plus supplements) was highest in breakfast non-consumers, intermediate in consumers of other types of breakfasts and lowest in consumers of RTEC breakfast. For vitamin A, P and Zn, breakfast non-consumers had a higher prevalence of nutrient inadequacy than both breakfast groups. The potential risk of excessive nutrient intakes was low in all groups. Efforts to encourage and maintain breakfast consumption in children and adolescents are warranted.

Prevalence and public health relevance of micronutrient deficiencies and undernutrition in pre-school children and women of reproductive age in Côte d'Ivoire, West Africa

OBJECTIVE

To provide nationally representative data on the prevalence of anaemia, vitamin A and Fe deficiencies among pre-school age children (pre-SAC) and non-pregnant women of reproductive age (WRA), and on vitamin B₁₂ and folate deficiencies in WRA, and the influence of inflammation on their interpretation.

DESIGN

A cross-sectional survey to measure anthropometry, malaria parasitaemia and micronutrient status. Specifically, blood samples were analysed for Hb, plasma ferritin, soluble transferrin receptors, C-reactive protein, α₁-acid glycoprotein, retinol-binding protein, vitamin B₁₂ and folate.

SETTING

Côte d'Ivoire in 2007.

SUBJECTS

Nine hundred and twenty-eight WRA and 879 pre-SAC.

RESULTS

In WRA, prevalence of Plasmodium parasitaemia (5 %) was low, but inflammation (34 %) was higher. Anaemia was a severe public health problem and prevalence differed by residency and eco-region. Inflammation-adjusted Fe deficiency was highest in urban areas (20 %). Nationally, folate deficiency was 86 %, higher in urban areas and varied by eco-region. Prevalence of vitamin B₁₂ deficiency was low but higher in the rural areas and the north. Inflammation-adjusted vitamin A deficiency was very low (1 %). In pre-SAC, prevalence of inflammation (67 %) and Plasmodium parasites (25 %) was high; the latter was associated with poverty, rural residency and higher ferritin concentrations. Anaemia was classified as a severe public health problem (72 %), and was higher in rural areas (76 %) and the north (87 %). A quarter of pre-SAC suffered from vitamin A deficiency (inflammation-adjusted) and prevalence of undernutrition was high.

CONCLUSIONS

Prevalence of inflammation, Plasmodium parasitaemia and micronutrient deficiencies were high in Côte d'Ivoire, particularly in pre-SAC. Nutritional interventions should be accompanied by strategies to reduce exposure to infections.

Mother's education is the most important factor in socio-economic inequality of child stunting in Iran

OBJECTIVE

Malnutrition is one of the most important health problems, especially in developing countries. The present study aimed to describe the socio-economic inequality in stunting and its determinants in Iran for the first time.

DESIGN

Cross-sectional, population-based survey, carried out in 2009. Using randomized cluster sampling, weight and height of children were measured and anthropometric indices were calculated based on child growth standards given by the WHO. Socio-economic status of families was determined using principal component analysis on household assets and social specifications of families. The concentration index was used to calculate socio-economic inequality in stunting and its determinants were measured by decomposition of this index. Factors affecting the gap between socio-economic groups were recognized by using the Oaxaca-Blinder decomposition method.

SETTING

Shahroud District in north-eastern Iran.

SUBJECTS

Children (n 1395) aged <6 years.

RESULTS

The concentration index for socio-economic inequality in stunting was -0·1913. Mother's education contributed 70 % in decomposition of this index. Mean height-for-age Z-score was -0·544 and -0·335 for low and high socio-economic groups, respectively. Mother's education was the factor contributing most to the gap between these two groups.

CONCLUSIONS

There was a significant socio-economic inequality in the studied children. If mother's education is distributed equally in all the different groups of Iranian society, one can expect to eliminate 70 % of the socio-economic inequalities. Even in high socio-economic groups, the mean height-for-age Z-score was lower than the international standards. These issues emphasize the necessity of applying new interventions especially for the improvement of maternal education.

Determinants of child malnutrition in rural and urban Ecuadorian highlands

OBJECTIVE

To identify and compare the sociodemographic determinants of stunting, wasting and overweight among infants of urban and rural areas in the Ecuadorian highlands.

DESIGN

Cross-sectional study.

SETTING

Nabon (rural) and Cuenca (urban) cantons, Azuay Province, Ecuador.

SUBJECTS

A total of 703 children aged 0-24 months and their caregivers (227 rural and 476 urban) recruited during the period from June to September 2008.

RESULTS

Stunting prevalence was significantly higher in the rural area (37·4 % v. 17·7 %; P < 0·001) while wasting (7·1 %) and overweight (17·1 %) prevalence were more similar between areas. Determinants of stunting for the pooled sample were male gender (OR = 1·43; 95 % CI 1·06, 1·92; P = 0·02), preterm delivery (OR = 1·65; 95 % CI 1·14, 2·38; P = 0·008), child's age (OR = 1·04; 95 % CI 1·01, 1·07; P = 0·011), maternal education (OR = 0·95; 95 % CI 0·92, 0·99; P = 0·025) and facility-based delivery (OR = 0·57; 95 % CI 0·45, 0·74; P < 0·001). The latter was also a determinant of overweight (OR = 0·39; 95 % CI 0·25, 0·62; P < 0·001). Rural determinants of stunting were maternal height (OR = 0·004; 95 % CI 0·00004, 0·39; P = 0·018), diarrhoea prevalence (OR = 2·18; 95 % CI 1·13, 4·21; P = 0·02), socio-economic status (OR = 0·79; 95 % CI 0·64, 0·98; P = 0·030) and child's age (OR = 1·07; 95 % CI 1·02, 1·11; P = 0·005). Urban determinants were: maternal BMI for stunting (OR = 0·91; 95 % CI 0·84, 0·99; P = 0·027), cough prevalence (OR = 0·57; 95 % CI 0·34, 0·96; P = 0·036) and facility-based delivery (OR = 0·25; 95 % CI 0·09, 0·73; P = 0·011) for overweight, and hygiene for wasting (OR = 0·57; 95 % CI 0·36, 0·89; P = 0·013).

CONCLUSIONS

Infant malnutrition was associated with different sociodemographic determinants between urban and rural areas in the Ecuadorian highlands, a finding which contributes to prioritize the determinants to be assessed in nutritional interventions.

The evaluation of maternal health in rural western China

OBJECTIVE

The double burden of undernutrition and overnutrition is recognized as a global devastating problem. However, few studies have investigated the maternal nutritional status among different ethnicities and the socio-demographic characteristics in rural areas of western China. This study attempted to fill this gap.

DESIGN

Data on 10,495 women with children under three years old were collected using a three-stage probability proportion to size sampling from 45 counties of 10 provinces in western China. Generalized Estimating Equation (GEE) was used to assess the maternal nutrition conditions, including chronic energy deficiency (CED) and overweight/obesity.

RESULTS

According to the WHO BMI standard, the prevalences of CED and overweight/obesity were 12.3% (BMI≤18.5 kg/m2) and 12.4% (BMI≥25 kg/m2), respectively, while overweight/obesity rate was 18.5% (BMI≥24 kg/m2) based on the Chinese standard. A significant difference in malnutrition between Han and Minority was not observed. The relationship between breastfeeding and CED was inverse (OR 0.64, 95%CI: 0.48, 0.87), but higher parity were positively correlated with CED (OR 1.57, 95%CI: 1.36, 1.82). The highest odds of CED were observed in the group with 1-5 years of education (OR 1.21, 95%CI: 1.03, 1.43). Higher parity was also associated with overweight/obesity (OR 0.78, 95%CI: 0.67, 0.91), and rural women aged 30-39 years old were more likely to be overweight/obese (OR 2.21, 95%CI: 1.47, 3.32). In addition, higher socioeconomic status was positively related to overweight women (OR 1.19, 95%CI: 1.01, 1.43), and inversely associated with CED (OR 0.83, 95%CI: 0.72, 0.97).

CONCLUSION

The coexistence of undernutrition and overweight among women of reproductive age are determined in rural western China. It appears that socio-demographic factors considerably influence maternal nutritional status in the study. These findings have important policy implications for recommendations on maternal health intervention in China.

Relative undernourishment and food insecurity associations with Plasmodium falciparum among Batwa pygmies in Uganda: evidence from a cross-sectional survey

Although malnutrition and malaria co-occur among individuals and populations globally, effects of nutritional status on risk for parasitemia and clinical illness remain poorly understood. We investigated associations between Plasmodium falciparum infection, nutrition, and food security in a cross-sectional survey of 365 Batwa pygmies in Kanungu District, Uganda in January of 2013. We identified 4.1% parasite prevalence among individuals over 5 years old. Severe food insecurity was associated with increased risk for positive rapid immunochromatographic test outcome (adjusted relative risk [ARR] = 13.09; 95% confidence interval [95% CI] = 2.23–76.79). High age/sex-adjusted mid-upper arm circumference was associated with decreased risk for positive test among individuals who were not severely food-insecure (ARR = 0.37; 95% CI = 0.19–0.69). Within Batwa pygmy communities, where malnutrition and food insecurity are common, individuals who are particularly undernourished or severely food-insecure may have elevated risk for P. falciparum parasitemia. This finding may motivate integrated control of malaria and malnutrition in low-transmission settings.

[Nutritional status and related factors of Tujia and Miao minority primary school students in Xiangxi Autonomous Prefecture]

OBJECTIVE

To understand the nutritional status and related factors of Tujia and Miao minority primary school students in Xiangxi Autonomous Prefecture and to provide refrence for the improvement of minority students' nutritional status.

METHODS

By the method of layered and random sampling, physique test and questionnaire survey were taken to 682 Tujia students and 420 Miao students, the nutritional level of students were estimated by the method of height with standard weight. Logistic regression analysis was used to analyze the risk factors of nutritional status.

RESULTS

The moderate malnutrition rate was 4.54% and the obesity rate was 11.43%. Logistic regression analysis showed that monthly income per capita (OR = 1.368, 95% CI 1.135-1.648) and culture level of fathers (OR = 1.332, 95% CI 1.108-1.602) were independent risk factors of malnutrition, children with family obesity history (OR =7.688, 95% C15. 134-11.513), monthly income per capita (OR = 1.516, 95% CI 1.204-1.910) and culture level of fathers (OR = 1.466, 95% CI 1.164-1.846 ) were independent risk factors of overnutrition.

CONCLUSION

Malnutrition and overnutrition exist in Tujia and Miao students at the same time, family obesity history, monthly income per capita and culture level of fathers are factors of malnutrition and overnutrition. Nutritional education should be taken universal to students and their guardians.

High malnutrition rate in Venezuelan Yanomami compared to Warao Amerindians and Creoles: significant associations with intestinal parasites and anemia

BACKGROUND

Children in rural areas experience the interrelated problems of poor growth, anemia and parasitic infections. We investigated the prevalence of and associations between intestinal helminth and protozoan infections, malnutrition and anemia in school-age Venezuelan children.

METHODS

This cross-sectional study was conducted in 390 children aged 4-16 years from three rural areas of Venezuela: the Amazon Region, Orinoco Delta and Carabobo State. Stool samples were collected for direct parasitic examinations. Anthropometric indicators of chronic (height-for-age Z score) and acute (weight-for-height and Body Mass Index (BMI)-for-age Z score in respectively children under 5 years of age and children aged 5 years and above) malnutrition were calculated. Multivariate linear and logistic regression models were built to determine factors associated with nutritional status and polyparasitism.

RESULTS

Hookworm and Strongyloides stercoralis prevalences were highest in children from the Amazon rainforest (respectively 72% and 18%) while children from the Orinoco Delta and Carabobo State showed higher rates of Ascaris lumbricoides (respectively 28% and 37%) and Trichuris trichiura (40% in both regions). The prevalence of Giardia lamblia infection was not significantly different between regions (average: 18%). Anemia prevalence was highest in the Amazon Region (24%). Hemoglobin levels were significantly decreased in children with a hookworm infection. Malnutrition was present in respectively 84%, 30% and 13% of children from the Amazon Region, Orinoco Delta and Carabobo State. In multivariate analysis including all regions, G. lamblia and helminth infections were significantly and negatively associated with respectively height-for-age and weight-for-height/BMI-for-age Z scores. Furthermore, hemoglobin levels were positively associated with the height-for-age Z score (0.11, 95% CI 0.02 - 0.20).

CONCLUSIONS

In rural populations in Venezuela helminthiasis and giardiasis were associated with acute and chronic nutritional status respectively. These data highlight the need for an integrated approach to control transmission of parasites and improve the health status of rural Venezuelan children.

Prevalence of food insecurity in patients with diabetes in western Kenya

AIMS

To determine the characteristics of patients with diabetes who reported food insecurity at three diabetes clinics in western Kenya.

METHODS

This study includes routinely collected demographic data at the first presentation of patients with diabetes at clinics in western Kenya from 1 January 2006 to 24 September 2011. A validated questionnaire was used to assess food insecurity with descriptive and comparative statistics being used to analyse the food-secure and food-insecure populations.

RESULTS

The number of patients presenting to these clinics who were food-secure and those who were food-insecure was 1179 (68.0%) and 554 (32.0%), respectively. Comparative analysis shows a statistically significant difference in weight, BMI, the presence of a caretaker, and use of insulin between the two groups. These variables were lower in the food-insecure group. The overall assessment of the clinic population revealed an abnormally high mean HbA1c concentration of 81 mmol/mol (9.6%).

CONCLUSIONS

Despite the widely recognized contribution of caloric over-nutrition to the development of diabetes, this study highlights the high prevalence of food insecurity amongst patients with diabetes in rural, resource-constrained settings. Other factors, such as the lower prevalence of obesity, poor glucose control, challenges in the use of insulin because of the risk of hypoglycaemia, and varying subtypes of diabetes in this population, point to the need for additional research in understanding the aetiology, pathophysiology and optimum management of this condition, as well as understanding the effects of enhancing food security.

Ongoing deterioration of the nutritional status of Palestinian preschool children in Gaza under the Israeli siege

This cross-sectional, community-based, household survey was carried out in Gaza City, Palestine during the first half of 2009 to study the nutritional status of Palestinian preschool children aged 2-5 years under blockade. The response rate was 95.2% from a total sample of 770. The majority (94.4%) of households faced difficulties accessing food, the main cause was the siege and the shortage of food products; and the majority (85.5%) were food insecure households. Just over 50% of the preschoolers were anaemic, 26.8% of those who had a stool test had parasitic infections, and 15.0 were stunted. Food insecurity was the first predictor of stunting andd underweight, and malnutrition indicators indicate the worst situation in the Gaza Strip for several decades.

Is Bangladesh going through an epidemiological and nutritional transition?

Bangladesh is going through an epidemiological transition with large reductions in mortality due to acute, infectious, and parasitic diseases and increases in non-communicable, degenerative, and chronic diseases over the last 20 years. There is also evidence of an adult nutritional transition with increases in pre-obesity and obesity particularly in urban areas. However a high percentage of the population of Bangladesh remain undernourished and economically poor and ultra-poor development programmes indicate that improving their nutritional status might not be achievable as a bi-product of the development programme. Bangladesh like many developing countries has many burdens of under and over-nutrition, high levels of infectious diseases as well as growing levels of non-communicable diseases.

[Analysis on growth and malnutrition status of Tibetan children aged 0 to 35 months in rural Lhasa in 2010]

OBJECTIVE

To understand the growth and malnutrition status of Tibetan children aged 0 to 35 months in rural Lhasa in 2010.

METHODS

Cross-sectional study and multistage sampling design were used to randomly select sampling units. A total of 640 children were studied. Height and weight were measured and nutritional status was evaluated with WHO reference in 2006 using Z-scores. Z-scores of weight-for-age (WAZ), Z-scores of height-for-age (HAZ) and Z-scores of weight-for-height (WHZ) were analyzed.

RESULTS

At the age of 18 - 35 months, the children in rural Lhasa were 3.0 cm shorter as compared to the China national length reference. At the age of 6 - 11, 12 - 17 months, weight ((8.84 ± 1.23) and (10.20 ± 1.08) kg) and length ((70.45 ± 4.46) and (76.73 ± 4.78) cm) of boys were significantly higher than girls (weight: (8.42 ± 1.30) and (9.59 ± 1.26) kg; length: (67.61 ± 3.98) and (74.25 ± 4.50) cm) (all P values < 0.05). WAZ and HAZ were -0.17 ± 1.11 and -1.11 ± 1.46, respectively. The HAZ of 18 - 23 months children (-1.51 ± 1.24) was significantly different from the HAZ of 0 - 5, 6 - 11, 12 - 17 months children (HAZ: -0.75 ± 1.50, -0.83 ± 1.72, -1.07 ± 1.55, respectively) (all P values < 0.05), comparison with the HAZ of 24 - 29, 30 - 35 months children (HAZ: -1.41 ± 1.25, -1.24 ± 1.05), the results showed that there were no significant difference (all P values > 0.05), HAZ of 18 - 23 months children was the lowest. The prevalence of stunting, underweight, and wasting were 24.6% (155/630), 5.4% (33/616) and 1.0% (6/608), respectively. The malnutrition of boys was more serious than that of girls, the stunting of 18 - 23 and 24 - 29 months children had reached 35.0% (36/103) and 29.1% (25/86), respectively.

CONCLUSION

The growth and development status of children in rural Lhasa under 3 years old was poor, and the malnutrition of local children should not be ignored with variations by gender and months of age.

Epilepsy, poverty and early under-nutrition in rural Ethiopia

PURPOSE

The incidence of epilepsy in Ethiopia is high compared with industrialised countries, but in most cases the cause of epilepsy is unknown. Childhood malnutrition remains widespread. We performed a case-control study to determine whether epilepsy is associated with poverty and markers of early under-nutrition.

METHODS

Patients with epilepsy (n=112), aged 18-45years, were recruited from epilepsy clinics in and around two towns in Ethiopia. Controls with a similar age and gender distribution (n=149) were recruited from patients and relatives attending general outpatient clinics. We administered a questionnaire to define the medical and social history of cases and controls, and then performed a series of anthropometric measurements. Unconditional logistic regression was used to estimate multivariate adjusted odds ratios. Multiple linear regression was used to estimate adjusted case-control differences for continuously distributed outcomes.

RESULTS

Epilepsy was associated with illiteracy/low levels of education, odds ratio=3.0 (95% confidence interval: 1.7-5.6), subsistence farming, odds ratio=2.6 (1.2-5.6) and markers of poverty including poorer access to sanitation (p=0.009), greater overcrowding (p=0.008) and fewer possessions (p<0.001). Epilepsy was also associated with the father's death during childhood, odds ratio=2.2 (1.0-4.6). Body mass index was similar in cases and controls, but patients with epilepsy were shorter and lighter with reduced sitting height (p<0.001), bitrochanteric diameter (p=0.029) and hip size (p=0.003). Patients with epilepsy also had lower mid-upper arm circumference (p=0.011) and lean body mass (p=0.037).

CONCLUSION

Epilepsy in Ethiopia is strongly associated with poor education and markers of poverty. Patients with epilepsy also had evidence of stunting and disproportionate skeletal growth, raising the possibility of a link between early under-nutrition and epilepsy.

Nutritional assessment by mid-upper arm circumference of santal adults of Purulia, West Bengal, India

The present community based cross-sectional study was undertaken to determine the prevalence of undernutrition using mid-upper arm circumference (MUAC) among adult (> 18 years) Santals of Purulia District, West Bengal, India. It was undertaken at 10 villages of the district. A total of 520 (217 males and 303 females) subjects were measured. Commonly used indicator i.e., MUAC and BMI, were used to evaluate the nutritional status of the subjects. More women (64.7%) then men (54.4%) based on MUAC and women (59.4%) then men (34.6%) based on BMI were undernourished. Significant sex difference both in MUAC (t=2.378, p<0.05) and BMI (t=4.971, p<0.001) were observed. Significant age group difference for MUAC was observed (F=8.93***, df=3) for men and (F=9.52***, df=3) for women. For BMI, these values were F=10.10*** (df=3) F=6.17*** (df=3) respectively. In conclusion, we found that adult Santals of both sexes were under critical nutritional stress, women and the oldest among them were the most.

The relationship of ethnicity, socio-economic factors and malnutrition in primary school children in north of Iran: a cross-sectional study

BACKGROUND

The main objective of this study was to assess the malnutrition and some socio-economic related factors based on three ethnic groups among primary school children in north of Iran in 2010.

METHODS

This cross-sectional study was carried out through multistage cluster random sampling on 5698 subjects (2505 Fars-native, 2154 Turkman, and 1039 Sistani) in 112 schools. Well-trained staffs completed the questionnaire and measured students' weight and height. Malnutrition estimated the Z-score less than -2SD for underweight, stunting and wasting were calculated using the cutoffs from WHO references.

RESULTS

Generally, malnutrition was observed in 3.20%, 4.93% and 5.13% based on underweight, stunting and wasting respectively. It was more common in girls than in boys and in Sistani than in other ethnic groups. The correlation between malnutrition based on underweight and stunting and ethnicity was statistically significant (P=0.001). Results of logistic regression analyses showed that the risk of malnutrition was in rural area 1.34 times more than urban area, in girls 1.17 times more than boys, in Sistani ethnic group 1.82 times more than Fars-native ethnic group, in low economic families 2.01 times more than high economic families.

CONCLUSION

Underweight, stunting and wasting are the health problems in primary school children in north of Iran with a higher prevalence in girls, in rural areas, and in Sistani ethnic group.

On hunger and child mortality in India

Despite accelerated growth there is pervasive hunger, child undernutrition and mortality in India. Our analysis focuses on their determinants. Raising living standards alone will not reduce hunger and undernutrition. Reduction of rural/urban disparities, income inequality, consumer price stabilization, and mothers’ literacy all have roles of varying importance in different nutrition indicators. Somewhat surprisingly, public distribution system (PDS) do not have a significant effect on any of them. Generally, child undernutrition and mortality rise with poverty. Our analysis confirms that media exposure triggers public action, and helps avert child undernutrition and mortality. Drastic reduction of economic inequality is in fact key to averting child mortality, conditional upon a drastic reordering of social and economic arrangements.

Relationship between child feeding practices and malnutrition in 7 remote and poor counties, P R China

The World Health Organization reported that inappropriate feeding in children is responsible for one-third of the cases of malnutrition. This cross-sectional study aimed to determine the prevalence of malnutrition and identify the relationship between feeding practices and malnutrition in children below 5 years, in 7 remote and poor counties of China. A sample of 2201 children and 1978 caregivers were obtained with multistage cluster random sampling. A survey about feeding practices among the caregivers was implemented using a structured questionnaire, and the health status of children was evaluated using anthropometric measurements. We found 5 problems: first, high prevalence of stunting, underweight and wasting in children below 5 years old (19.3%, 13.1% and 5.5%); second, short duration of breastfeeding for children below 36 months; third, low prevalence of exclusive breastfeeding among children below 6 months of age and continued breastfeeding to 1 year (17.5% and 32.2%). Fourth, although most of the infants (81.1%) between 6 and 8 months of age were given complementary foods, some of the 6- to 8-month-old infants did not receive any complementary foods. Last, a higher prevalence of stunting among Chinese children who had never been breastfed, who had been breastfed for less than 1 year, or had been fed with semi-solid foods of poor quality. Therefore, we suggest that more programs to increase caregivers' feeding knowledge and practices be conducted, to improve the health of children in remote and poor areas in China.

Trends in the prevalence of undernutrition, nutrient and food intake and predictors of undernutrition among under five year tribal children in India

Undernutrition among children under five year is a significant public health problem in India. The present study was carried out to assess trends in nutritional status, nutrient and food intake among children under five year over two time periods. It was a community-based cross-sectional study, carried out in tribal areas of India. A total of 14,587 children, 0-5 years old were covered for nutritional assessment in terms of underweight, stunting and wasting. A 24 hour diet survey was carried out in a sub-sample of households surveyed. Wealth index was constructed using principle component analysis. The prevalence of underweight and stunting had declined significantly over the periods (49% vs 57%, 51% vs 58%, respectively), while the prevalence of wasting remained similar (22% vs 23%). There was marginal decrease in the intake of foods and nutrients over the periods, and was below recommended levels. Stepwise regression showed that the risk of underweight and stunting was significantly (p<0.01) higher among children of illiterate mothers and children from lowest and middle households wealth index. Morbidities during preceding fortnight had 1.3 times higher risk of underweight and wasting. In conclusion, undernutrition is a significant health problem among tribal children and is associated with literacy status of mothers, household wealth index and morbidities. Therefore implementation of appropriate nutritional intervention strategies and improvement in households food security through public distribution systems, food intakes, socioeconomic condition, literacy of parents and personal hygiene may help in improving the nutritional status of tribal children.

The U-shaped relationship between BMI and all-cause mortality contrasts with a progressive increase in medical expenditure: a prospective cohort study

The U-shaped relationship between body mass index (BMI) and all-cause mortality has generated uncertainty about optimal BMI. For clarification, we have related BMI to both mortality and medical expenditure. The MJ Health examination cohort of 111,949 examinees established during 1994-1996 was followed with endpoint information derived from death certificates and National Health Insurance records from 1996 to 2007. Age- and gender-specific relative risks between BMI groups were estimated by Cox and logistic regressions. The BMI and all-cause mortality relationship is U-shaped with the concave regions sitting in the region of BMI 22-26, butshifted rightward for the elderly. After excluding smokers and cancer patients at baseline, the low mortality region moved leftward to BMI 20-22. Cause-specific mortalities from respiratory disease, injury, and senility increased in the underweight group (BMI <18.5). Above 18.5, BMI was negatively associated with mortality from respiratory diseases and senility, but not with others. In contrast, irrespective of age and gender, the overall median and mean medical expenditures progressively increased with BMI, particularly beyond 22. Expenditures for injury, respiratory, circulatory diseases and senility all increased with BMI. The U-shaped BMI-mortality relation was a result of elevated death rate at both ends of the BMI scale. Increased mortality at the low end did not contribute to higher medical expenditure, maybe because the lean and frail deceased tend to die abruptly before large amount of medical expenditure was consumed. Our findings suggest that current recommendations to maintain BMI at the lower end of the desirable range remain tenable for the apparently healthy general public.

Fish oil supplementation is beneficial on caloric intake, appetite and mid upper arm muscle circumference in children with leukaemia

A randomised trial was carried out to determine the effect of supplementation of fish oil among 51 children with leukaemia aged 4 to 12 years on appetite level, caloric intake, body weight and lean body mass. They were randomly allocated into the trial group (TG) and the control group (CG). At baseline, 30.8% of TG subjects and 44.0% of CG subjects were malnourished and 7.7% of subject from TG and 28.0% from CG were classified as stunted. The majority of subjects from TG and CG were in the mild malnutrition category for mid upper arm muscle circumference (MUAMC)-for-age. The TG group showed significant increment in MUAMC (0.13 cm vs -0.09 cm) compared with CG at 8 weeks (p<0.001). There was a significant higher increase for appetite level (0.12±0.33) (p<0.05) and an increasing trend on energy and protein intake in the TG group (213±554 kcal; 3.64 ±26.8 g) than in the CG group. In conclusion, supplementation of fish oil has a positive effect on appetite level, caloric intake and MUAMC among children with leukaemia.