outline childhood stunting -...

TM

Optimizing nutrition

in stunted children:

Interventions and practices

Umaporn Suthutvoravut

Faculty of Medicine Ramathibodi Hospital

Mahidol University

• Background information

• Nutrition intervention

• Practice in Thailand

• Conclusion

Outline Childhood stunting

• Short stature for age

• Indicator of chronic undernutrition

• Defined by length or height below – 2 SDs from the WHO Child Growth Standards (or an acceptable reference) median for the same age and sex

ILSI SEA Region Seminar on Maternal, Infant and Young Child Nutrition – Updates on Cambodia, Lao PDR and MyanmarAugust 11, 2016, Phnom Penh, Cambodia

Classification Definition Grading

Gomez

(1956)

Weight below 90%

median WA

Mild (grade 1)

Moderate (grade 2)

Severe (grade 3)

75%-90% WA

60%-74% WA

<60% WA

Waterlow

(1972)

Weight below 90%

median WH

Mild

Moderate

Severe

80%-90% WH

70%-80% WH

<70% WH

WHO (1983)

(wasting)

WH Z-score below

-2

Moderate

Severe

-3 z-score <-2

z-score <-3

WHO (1983)

(stunting)

HA Z-score below

-2

Moderate

Severe

-3 z-score <-2

z-score <-3

HA, height for age; WA, weight for age; WH, weight for height; WHO, World Health Organization

Modified from Grover Z, et al. Pediatr Clin North Am 2009;56:1055-68.

Definition of malnutrition Waterlow classification

Severity

Acute

Weight for height

(% of median)

Chronic

Height for age

(% of median)

Normal >90 >95

Mild 80-90 90-95

Moderate 70-80 85-90

Severe <70 <85

Childhood stunting

• Often occurs in utero and extends through infancy and childhood

• Severe short-term and long-term health and functional consequences

2 months

In uterus 5 months

In uterus

Newborn 2 years 6 years 12 years 25 years

At Birth 6 Yars Old 14 Years Old

First 1,000 days of life


UNICEF Report: Critical Importance of First 1,000 Days of Life Friday, April 19, 2013 World attention is increasingly focused on the most critical period experienced by everyone on earth-the first 1,000 days of life from conception to the second birthday.

"It is difficult to think of a greater injustice than robbing a child, in the womb and in infancy, of the ability to fully develop his or her talents throughout life. This is a tragedy for the 165 million children under the age of 5 afflicted by stunting in the world today. It is a violation of their rights. It is also a huge burden for nations whose future citizens will be neither as healthy nor as productive as they could have been."

Anthony Lake, Executive Director of UNICEF

Linear growth & child development

in LMICs: Meta-analysis

• 68 studies in 29 low- and middle-income countries

• Cross-sectional and prospective studies

Sudfeld CR et al. Pediatrics 2015; 135: e1266-75.

Multivariate adjusted cross-sectional SMD in cognition per unit increase in HAZ stratified by age at measurement.


+ 0.24

+ 0.09

Multivariate adjusted prospective SMD in

cognition per unit increase in HAZ.


+ 0.22


• 5 long-standing prospective cohort studies from Brazil, Guatemala, India, Philippines, South Africa

• Poor fetal growth or stunting in the first 2 years of life leads to irreversible damage including shorter adult height, lower attained schooling, reduced adult income, decreased offspring birth weight

• Children who are undernourished in the first 2 years and put on weight rapidly later are at high risk of diet-related chronic diseases

Victora CG et al. Lancet 2008

Maternal and child undernutrition:

Consequences for adult health & human capital 40%reductionin the number of children under-5 who are stunted.

Framework of the relations between poverty, food insecurity, and other underlying and immediate causes to maternal and child undernutrition and its short-term and long-term consequences

Black RE, et al. Lancet 2008.

Maternal and child

undernutrition

Short-term consequences:

Mortality, morbidity, disability

Long-term consequences:

Adult size, intellectual ability, economic

productivity, reproductive performance,

metabolic and cardiovascular disease

Inadequate dietary

intake Disease

Inadequate care Unhealthy household environment

and lack of health services

Household food

insecurity

Income poverty: employment, self-

employment, dwelling, assets,

remittances, pensions, transfers etc

Lack of capital: financial, human,

physical, social, and natural

Social, economic, and political context

Immediate

causes

Basic

causes

Underlying

causes

Changes in stunting prevalence

between 1996-2010 in SEA countries

Bloem MW et al. Food Nutr Bull 2013;34:S8-16.

32 36 44 17 35 30 0 16 19

Globalnutritionreport.org 2015


Stunting rates by Gross Domestic Product

in selected ASEAN countries: 2010 data

Bloem MW et al. Food Nutr Bull 2013;34:S8-16.

Optimal

catch-up

growth

Energy

Protein

Micro-

nutrients

Treat

causes

• Depend on severity (wasted, wasted and stunted) and causes

• Estimated energy need by using ideal body weight for height or energy/kg actual body weight plus 10-50%

• Estimated protein requirement of wasted children are 9-11.5 % of total energy, depending on the rate and composition of weight gain

Energy & protein requirement

to catch up

Report of Joint WHO/FAO/UNU Expert Consultation, 2007. Nevin-Folino N (ed). Ped Manual Clin Dietetics, 2003. Sullivan PB and Goulet O (eds). EJCN 2010; 64 (Suppl 1)

Protein Amino

acids Bone growth

Growth

hormone,

zinc IGF-1*

Stimulate chondrocyte &

osteoblast

Intestinal Ca, P

absorption

25(OH)D3 1,25(OH)2D3

Renal tubular

P absorption *Insulin-like growth factor-1

Protein and bone growth


Dietary protein

Endogenous acid

production

Renal tubular

Ca reabsorption

Direct physico-

chemical

dissolution of bone

Cell-

mediated

bone

resorption

Urinary calcium loss

Bone loss

Protein & Energy

Vitamins: D, K, A, C

Minerals:

Ca, P, Mg, Na, K

I, Zn, Cu, Fe, F

Major nutrients for bone growth

www.bbc.co.uk

Successful nutrition

intervention

• Integrated approaches

• Combined with infection control and child development intervention

• Cover both pregnancy and post-natal periods

Nutrition interventions

• Dietary diversification

• Selection of nutrient-rich foods

• Exclusive breastfeeding 0-6 months

• Improved complementary feeding practice

• Staple food fortification eg. iron, zinc

• Multiple micronutrient supplementation

• Use of fortified food products specifically formulated for these target groups


Dietary diversification &

Selection of nutrient-rich food

• Food-Based Dietary Guidelines & Food Guide

• Challenges: Implementation and evaluation

• Healthy food environment and effective partnership among various sectors i.e. government, food industry/producer, agriculture, health service, nutrition, education, community

Hans de Beer. Economics & Human Biology 2012.

Dairy products and physical stature

• Systematic review and meta-analysis of controlled trials

• 12 studies: 7 randomized controlled trials and 5 non-randomized controlled trials

• Sample size 36-757 participants

• Age 3-13 years

• Country: Europe (3), USA (2), China (2), Indonesia (2), Northern Vietnam, Kenya, India

Forest plot of trials comparing height increases in supplementation groups versus usual diet or usual diet plus calorie supplement groups.

Hans de Beer. Economics & Human Biology 2012.

Additional growth of 0.4 cm/year/245 ml of milk daily

Dairy products and physical stature

0.59 cm

Lactose maldigestion (LM)

and intolerance (LI) in Thais

Subject N Test food LM(%) LI (%)

Children, 5-6 y 101 250 ml milk between

meal

15 0

250 ml milk+snack 12 0

Adolescents,13-16 y 324 250 ml milk 38 18

Adults, 18-45 y 93 250 ml milk 69 64

24

LM

125 ml milk 42

23

LM

250 ml milk+sandwich 21

29

LM

Yoghurt 15 4

Middle age, 45-60 70 Milk 57 64

40 Low lactose milk 17 36

40 Lactose-free milk 11 6

Sirichakwal PP, et al. 1989-2002


zinc

Catalytic Structural Regulatory

Clinical manifestation of zinc deficiency

Growth retardation (stunting)

Weight loss (wasting)

Delayed puberty

Hypogonadism & hypospermia

Poor appetite, hypogeusia, dysgeusia

Diarrhea

Impaired immunity, increase susceptibility to infection

Clinical manifestation of zinc deficiency

Skin lesions: dermatitis, erythematous, vesiculobullous, pustular, acro-orificial lesion

Glossitis, nail dystrophy, hair loss

Eye lesions: photophobia, impaired dark adaptation, blepharoconjunctivitis

Delayed wound healing

Behavioral abnormality

Low birth weight, prematurity

• Meta-analysis of randomized controlled trials

• 33 RCTs in children aged < 12 years (majority in <5-year-old children)

• Various dosage (1-20 mg/day)

• Duration 8 weeks -15 months

• Most studies provided ZnSO4

Zinc supplementation and linear

growth: Meta-analysis of RCT

Brown KH et al. Am J Clin Nutr 2002.


Weighted mean effect size and 95% CI (in SD units) for the effect of zinc

supplementation on children's linear growth by the subjects' mean initial

HAZ, WAZ, age, and serum zinc concentration

Brown KH et al. Am J Clin Nutr 2002.

• Systematic review and meta-analysis of randomized controlled trials

• 21 RCTs in infants (n=9), 1-5 year-old (n=6), > 6 year-old children (n=6)

• Various dosage (1-3 mg/kg/day – 3 mg/kg/week)

• Various iron preparation

• Duration 6 weeks -12 months

No effect of iron intervention on height

Vucic V et al. Nutr Rev 2013.

Strategies for prevention and control of malnutrition in Thailand

• Food/micronutrient supplementation

• Food fortification

• Food security

Food & Nutrients

• Public health measures: immunization, sanitation, water supply, deworming, growth monitoring, etc

• Community-based approaches

Public health &Community

• Food regulation

• Food and nutrition education/communication

Regulation& Education

Capacity building, Research & Development

“National food Fortification Committee” (appointed 1993 by MoPH) - Mandate : Support food fortification to improve micronutrient nutrition - Fortified product development : eg. universal salt iodization; iron, iodide, VA fortified instant noodle seasoning mix; iron and iodide in fish sauce Dietary diversification - Development and modification of Food Composition Table - Promotion of micronutrient-rich food production - Development of dietary guidelines and micronutrient-rich menu - Dietary guidelines for preparation of complementary foods from locally available raw materials for children of different age groups Development of national food-based dietary guidelines - FBDGs and Nutrition Flag - FBDGs for pregnant women - FBDGs for infants & preschool children

Food fortification and Food-based Dietary

Guidelines in Thailand

36


Food-Based Dietary Guidelines (FBDGs)

for Infants and Young Children, 2009

• Bureau of Health Promotion,

Ministry of Public Health

o Guidelines for antenatal care

o Guidelines for infant and young child feeding, care, immunization

o Record of growth, immunization

Maternal and child health record

Dietary guidelines: Pregnancy Dietary guidelines: Infants and young children


Micronutrient supplementation

• Iodine, folic acid, iron supplementation for pregnant and lactating women : daily dose

• Iron supplementation for pre-school and school-age children : weekly dose

School milk program in Thailand

Implemented as national programs since 1992

Based on Food and Nutrition Plan aiming to provide 200 ml/day of milk to children in kindergartens and primary school for 230 days/ year

An example of inter-sectoral linkage between education, agriculture, industry, local administration and health

Creating demand for local dairy industry which has grown significantly

• Optimizing nutrition support in stunted children is essential to reduce the short- and long-term consequences of malnutrition

• Integrated approaches: nutrition intervention should be combined with other public health intervention

• Prevention of childhood stunting by proper nutrition in pregnancy and post-natal periods

Conclusion


outline childhood stunting -...

Documents