Factors Associated With Early

Growth in Egyptian

Infants: Implications for

Addressing the Dual Burden

of Malnutrition

Presenter:

Core Group Fall Meeting, October 8, 2015

Justine Kavle, PhD, MPH

Senior Technical Officer, MCSP & PATH

Acknowledgements:

Study Team/Collaborators

Dr. Valerie Flax, University of North Carolina, USA

Dr. Ali Abdelmegeid, Jhpiego/MCSP and Mr. Farouk Salah, MCHIP Smart

Project Egypt

Ms. Seham Hafez, study coordinator, American University in Cairo (AUC)

Dr. Gulsen Saleh, Nutritionist & local PI, MCHIP Smart Project, Egypt

Dr. Mervat Ahmed Fouad, Dr. Doaa Hamed, Dr. Magda Ramzy, Nutritionists

affliated with National Nutrition Institute of Egypt

Ms. Rae Galloway, Maternal and Child Survival Program (MCSP)/PATH

3

One in four Egyptian children are stunted and 15% of children

younger than 5 years is overweight

Egypt faces “ the double burden of malnutrition”

Black, 2013, Lancet

Short term: Decreased mortality, morbidity, health expenditures, improved cognitive

development

Adequate growth and development: attainment of height potential and adequate weight

Household and family factors- maternal diet, care practices, food allocation

Community and Societal factors - Access to food and water, beliefs and norms, caregivers and care practices, agriculture and food

systems

Early initiation and exclusive breastfeeding

Adequate complementary

feeding – quantity, quality, diversity,

frequency

Prevention of infection

Long term: Decreased obesity and illnesses,

increased school performance, learning

capacity, work productivity, GDP

WHO Framework on Prevention of Stunting*

*Kavle et al 2014, Adapted from Stewart, 2013

Dual burden of malnutrition has consequences

for health and economic development

• Stunted children become stunted adults

• Decreased work capacity, productivity,

• Increased risk of obesity and other diseases

• Economic cost

• 20.3 billion Egyptian pounds – 1.9% gross domestic

product – losses in labor productivity due to stunting

• $9.1 billion Egyptian pounds - losses due to chronic

diseases due to obesity

Study Rationale, Objectives, and Methodology

Rationale for study: Stunting in children has nearly doubled in

Lower Egypt, which coincided with the avian influenza

outbreak, yet little is known about what may explain this rise

18 19

29

2124

36 36

2724

31

Frontier Lower Egypt Upper Egypt Urban Gov. All Egypt

Egypt Demographic and Health Surveys

2005 2008

Study Sites: Allow for comparisons between highest and

lowest levels of stunting in Smart Project sites

Kafr Shokr,

Qaliobia, Lower

Egypt

El-Maragha,

Sohag, Upper

Egypt

Four Part Implementation Science Study Examining

Factors Related to Stunting

Lower Egypt

1. Prospective follow-up of children’s

growth in the first year of life

(birth-12 months)

N =295

2. In-depth interviews

with pregnant and

postpartum women

N = 120

3.TIPS Mothers

with children less than 2 years

– Qualitative,

diet

N = 150

4. In-depth interviews with

fathers, grandmothers

and health workers

N= 120

Upper Egypt

Objectives

• To determine if there were differences in growth patterns

and factors related to growth in Lower and Upper Egypt

within the context of a U.S government funded maternal and

child health program

• To examine the relationship between weight and length to

ascertain if weight loss in any two-month interval

contributed to stunting at 12 months of age

Methods

• Longitudinal follow-up - 295 mother-infant pairs

• Data collection by CHW home visits- birth to 1 year

• Weight, length - z-score calculated WHO growth standard

• Program exposure

• Maternal report of infant illness

• 24 hour recall - dietary intake – trained nutritionists

• Multivariate mixed models- patterns/predictors of growth

• Weight-for age, length for age, weight for length

• Controlled for sex, maternal height, parity, maternal education & birth z-score

• Accounted for clustering and measuring same individual – over time

• Logistic regression – weight loss and stunting

Study data collection and MCHIP/SMART

program elements in Egypt

Study visits Data collection elements Elements of MCHIP/SMART

program

Birth Infant weight and length

Socio-demographic information

2 months*

Maternal weight and length

• Counselling session on what

to expect during the first

pregnancy

• Monthly session on good

nutrition during pregnancy

• Message on danger signs

during pregnancy

Exposure to program elements

• Receipt of iron pills

• Message on importance of

iron pills to avoid anemia

• Message on plan for

childbirth

• Message on mother and

infant health after delivery

*SMART program exposure levels: Low 0-5 elements, Medium = 6-10 elements, High = 1-15 elements

Study data collection and MCHIP/SMART

program elements in Egypt

Study visits Data collection elements Elements of

MCHIP/SMART program

4 months*

6, 8, 12 months**

Infant weight and length

• Receipt of medical examination

• Attendance of husband/mother-in-law at any awareness session

• Messages on feeding** when sick, care of child when sick, family planning and handwashing

• Messages on complementary feeding**

Exposure to program

elements

Infant dietary intake

*SMART program exposure levels: Low = 0-3 elements, Medium = 3-5 elements, High = 6-8 elements

**SMART program exposure levels: Low = 0-3 elements, Medium = 4-6 elements, High = 7-9 elements

Key Findings

Characteristics of mothers and infants,

Lower and Upper Egypt

Characteristic Lower Egypt

(n=142) Upper Egypt

(n=135)

Maternal

Mean age at delivery (±SD), years

25.7 ± 4.3 27.8 ± 5.7**

Mean height at 2 months postpartum

(±SD), cm 159.5 ± 6.8 158.5 ± 5.0

Mean parity (±SD) 1.1 ± 1.2 1.7 ± 1.7**

Completed secondary or higher level education, %

(n) 76 (108) 49 (80)***

Infant’s sex % (n)

Female 46 (66) 51 (69)

**p< 0.01, ***p < 0.001

Kavle et al., 2015

Percentage of infants, stunted and wasted,

Lower and Upper Egypt

8 6 5

12

24

10

3

18 16 11 10

4 1 1 0

14

7 5 2 1

0%

10%

20%

30%

40%

50%

60%

70%

80%

Birth 4 months 6 months 8 months 12 months

% Infants Stunted % Infants Stunted % Infants Wasted % Infants Wasted

Percentage of infants, underweight and

overweight, Lower and Upper Egypt

3 3 1 0 0 2 6 5 4 4

13

6 10

19

30

11

2

15 17

10

0%

10%

20%

30%

40%

50%

60%

70%

80%

Birth 4 months 6 months 8 months 12 months

% Infants Underweight % Infants Underweight

% Infants Overweight % Infants Overweight

Predicted patterns of infant growth:

weight-for age z-score, length-for-age z-score in Egyptian

infants

Kavle et al., 2015

-1.5

-1

-0.5

0

0.5

1

1.5

2

0 2 4 6 8 10 12

Pre

dic

ted

we

igh

t-fo

r-ag

e z

-sco

re

Age (months)

-1.5

-1

-0.5

0

0.5

1

1.5

2

0 2 4 6 8 10 12

Pre

dic

ted

len

gth

-fo

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e z

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Age (months)

Compared to 4 month visit, all visits associated with higher WAZ and lower LAZ p< 0.05 ------ Lower Egypt Upper Egypt

Predicted weight-for-length z-score in Egyptian

infants

Kavle et al., 2015

-1.5

-1

-0.5

0

0.5

1

1.5

2

0 2 4 6 8 10 12Pre

dic

ted

we

igh

t-fo

r-le

ngt

h z

-sco

re

Age (months)

Lower Egypt Upper Egypt

Compared to 4 month visit, all visits associated with higher WLZ p< 0.05

Predictors of growth, infants 4 & 6 months of age

4 months 6 months Lower Upper Lower Upper Morbidity Diarrhea (%) 16 17 20 21 Fever (%) 41 42 50 50

Dietary diversity

Mean (SD) number of food groups

0.5 ± 0.8 0.8 ± 0.8 2.0 ± 0.8 1.7 ± 1.0

Minimum dietary diversity (%)

17 21 7 9

Smart Program Exposure

Low (%) 40 33 59 56

Medium (%) 38 39 32 33

High (%) 22 28 9 11

Kavle et al., 2015

Predictors of growth, infants 8 & 12 months of age

8 months 12 months

Lower Upper Lower Upper

Morbidity

Diarrhea (%) 21 10 12 13

Fever (%) 46 54 39 53

Dietary diversity

Mean (SD) number of food groups

2.9 ± 1.0 2.7 ± 1.1 3.6 ± 1.0 3.6 ± 1.1

Minimum dietary diversity (%)

27 32 52 59

Smart Program Exposure

Low (%) 69 76* 66 76**

Medium (%) 12 17 17 24

High (%) 19 8 17 0

*p <0.05, **p< 0.001

Factors associated with infant growth

Upper and Lower Egypt

- Minimum dietary diversity was significantly associated with

weight for length Z-score in Lower Egypt

- 15-20% of energy intake comprised of junk/processed foods,

only half met WHO cut-off for dietary diversity

- No significant association with fever/ diarrhea or program

exposure and growth outcomes

- Weight loss at any interval was associated with greater odds

of stunting ( OR 2.0, p < 0. 05), Lower Egypt only

Kavle et al., 2015

Study Limitations

• Only 295 infants – larger sample size may have aided our

ability to detect associations

• Focus on period of infancy, yet stunting peaks at 18-23 months

• Lack of association of illness with growth

• Difficulty obtaining data on severity of illness by maternal

interview

Kavle et al., 2015

Implications for nutrition programs:

stunting and overweight

• Overweight and stunting begin in the first year of life

• 25% of infants stunted and 30% overweight by 12 months

• Weight loss during first year of life associated with

stunting at 12 months of age in Lower Egypt.

• Infant and young child nutrition programs need to

promote dietary quality while addressing dietary intake

patterns, reliance on energy-dense processed foods

• Need to develop interventions for double burden of

malnutrition

Kavle et al., 2015

Study findings published in Maternal and Child Nutrition

Journal Sept, 16, 2015 - Free open access

http://onlinelibrary.wiley.com/doi/10.1111/mcn.12213/abstract

For more information, please visit

www.mcsprogram.org

This presentation was made possible by the generous support of the American people through the

United States Agency for International Development (USAID), under the terms of the Cooperative

Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not

necessarily reflect the views of USAID or the United States Government.

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