NEW WHO GROWTH CURVES Why in QATAR? Ashraf T Soliman MD PhD FRCP

NEW WHO GROWTH CURVES Why in QATAR? Ashraf T Soliman MD PhD FRCP

Qatar CIA World Factbook demographic statistics. Population : 928,635 (July 2008 est.) Age structure : 0-14 years: 23.7% (male 104,453; female 100,295) 15-64 years: 72.9% (male 427,118; female 191,830) 65 years and over: 3.4% (male 21,599; female 7,756) (2005 est.) Population growth rate 2.50% (2006 est.) Birth rate 15.54 births/1,000 population (2005 est.) Death rate 4.61 deaths/1,000 population (2005 est.) Infant mortality rate 18.61 deaths/1,000 live births (2005 est.) Total fertility rate 2.87 children born/woman (2005 est.)

What are the Nutritional Problems In Qatar?

Obesity & Underweight in Qatar The prevalence of obesity was highest at 12 years of age among boys (11.7%) and at 13 years among girls (6.4%). The prevalence of underweight was highest at 16 years of age among boys (10.5%) and at 17 years among girls (8.9%). Food and nutrition bulletin Reference: 2006-Mar; vol 27 (issue 1) : pp 39-45

Prevalence of obesity among primary school-age children in Qatar (April 2003) Conducted by : Dr Fauzia Al-Khalaf Consultant Pediatric Endocrinology Reviewed by : Prof Ashraf T soliman Professor of Ped Endocrinology Funded by: The High supreme Family council

Subjects & methods Tools of the study: 1- Anthropometrics measures (Wt & Ht) 2- BMI = wt(kg)/ht(m2) 3- Sex & age specific BMI percentile of CDC growth chart 4- Used cutoff points: * overweight BMI for age 85 th 95 th percentile * Obesity BMI for age > 95 th percentile

Table (1) Sociodemographic characteristic of children under the study (n=4291) Nationality Sex Qatari Variable No % Non Qatar Male Female 2587 1704 2187 2104 60.3 39.7 51 49

Relationship between BMI percentile and gender Overweight Obese Boys Girls 9.7% 13.5% 14.3 % 15.2% In Australia 15% of boys & 15.8% of girls overweight, 4.5% of boys, 5.3% of girls obese

Obesity in Qatar

The prevalence of iron deficiency anaemia in the Arab Gulf Preschool children ranged from 20% to 67%, School children ranged from 12.6% to 50%. Pregnant women 22.7% to 54%. Infant feeding practices, food habits, parasitic infection, parity, early age at marriage, and geographical location are among the most important factors associated with iron deficiency anaemia in this region. Programmes to prevent and control this anaemia, are urgently needed. Nutrition and health vol. 16, n o 3, pp. 161-171, 2002

Vitamin D Deficiency in Qatar 85% of adolescents have VDD Acta Diabetol. 2008 Oct 10. The study revealed that vitamin D deficiency was highly prevalent in Qatari adolescents (11-16 years old; 61.6%), In the 5-10 year olds (28.9%) and In those below 5 years old (9.5%). Int J Food Sci Nutr. 2008 Oct 22:1-11

CAN THESE GROWTH DISORDERS BE DETECTED EARLY YES By-- GROWTH CHARTS

Existing Problems in Use of Growth Cards Growth Curves National/ Regional standards not defined Low awareness among community on importance of growth monitoring Data from public hospitals not available Private health sector not involved Low counselling skills in health care providers Weak training and supervision Non-availability of suitable weighing scale for community health workers Source: PIHS, PSLSM 2004-05

Growth Charts used in Qatar. Weight for Age.

WHO Child Growth Standards 0-5 years Innovative aspects Prescriptive approach recognizing need for standards 1. Breastfed infant as normative model 2. International sample 3. Reference data for assessing childhood obesity

CDC Vs WHO The WHO standards are based on a sample of healthy breastfed infants with high-quality complementary diets and provide a better tool than the CDC 2000 growth charts for monitoring the growth of breast-fed infants

CDC Vs WHO The CDC curves probably fail to capture the rapid and changing rate of weight gain in early infancy. In contrast, the infancy portion of the WHO standard is based on a much larger sample size (428 boys and 454 girls) and shorter measurement intervals [at birth, d 7, d 14, and then every 2 wk up to 2 mo and monthly thereafter These design characteristics allowed the WHO curves to capture the rapidly changing pattern of growth in early infancy, including the physiological weight loss that takes place in the first few days of life

Mean weight-for-age Z-scores of healthy breast-fed infants relative to the WHO standard and the CDC chart.

DIFFERENCES WHO Vs CDC J. Nutr. 137:144-148, January 2007 There are important differences between the WHO standards and the CDC charts that vary by age group, growth indicator, and specific Z-score curve. For weight-for-age, differences are particularly important during infancy. The establishment of the breast-fed child as the norm for growth brings coherence between the tools used to assess growth and U.S. national infant feeding guidelines that recommend breast-feeding as the optimal source of nutrition during infancy

CDC Vs WHO The comparison of the weight-for-length and weight-forheight charts shows that the U.S. children are generally heavier than those included in the WHO sample

CDC Vs WHO The WHO's weight-for-length curves extend to a greater length than the CDC curves (110 cm vs. 103 cm) to facilitate assessment of tall 2-y olds and older children who, for whatever reason (e.g., malnutrition or agitation), are unable to stand. Similarly, the WHO weight-for-height curves start earlier (65 cm) than the CDC curves (78 cm) to facilitate assessment of populations with high rates of stunting

Weighing Scale usually used in Health Facilities Salter Scale ( LHW ) Infant Clinical Scale Weight-height scale Uniscale (Mother-child electronic scale)

Longitudinal growth of infants in Qatar: comparison with WHO and CDC growth standards. Soliman A, Eldabbagh M, Khalafallah H, Alali M, Elalaily RK. Indian Pediatr. 2011 Oct;48(10):791-6. Epub 2011 May 30.

STATURE GROWTH

Length (cm) Growth in length Boys in Qatar vs WHO data 100 90 80 70 60 Q-Boys Mean length Mean + 2SD Mean - 2SD WHO-Mean WHO-Mean+ 2SD WHO-Mean-2SD 50 40 30 0 2 4 6 12 18 Age (months)

Length (cm) Growth in length girls in qatar vs WHO 100 90 80 70 60 Q-Girls Mean length Mean + 2SD Mean - 2SD WHO-Mean WHO-Mean+ 2SD WHO-Mean-2SD 50 40 30 0 2 4 6 12 18 Age (mon)

Length (cm) Growth in length boys in Qatar Vs CDC data 100 90 80 70 60 Q-Boys Mean length Mean + 2SD Mean - 2SD CDC- Mean Mean + 2SD Mean - 2SD 50 40 30 0 2 4 6 12 18 Age (mon)

Weight (kg) Growth in length Girls in Qatar vs CDC data 100 90 80 70 60 Q-Girls Mean length Mean + 2SD Mean - 2SD CDC Mean Mean + 2SD Mean - 2SD 50 40 30 0 2 4 6 12 18 Age (mon)

Weight Growth

Longitudinal growth data for infants in Qatar were compared to growth standards published by the CDC and WHO. 300 randomly selected full-term normal infants (150 males, 150 females) in Qatar were followed-up and weight and length were sequentially recorded at 2 months, 4 months, 6 months, 12 months and 18 months age.

The mean length for age of girls was higher than those published by the CDC and WHO at 12 and 18 months of age. Using the CDC standard for weight for length detected more wasted infants (9.0% and 6.5%) compared to using WHO standards (6.27% and 6.0%) for males and females, respectively.

Weight (kg) Growth in weight boys in Qatar vs WHO standards 16 14 12 10 8 6 Boys Mean Wt Mean + 2SD Mean - 2SD WHO boys mean Mean + 2SD Mean - 2SD 4 2 0 0 2 4 6 12 18 age (mon)

Weight (kg) Growth in weight girls in Qatar vs WHO 16 14 12 10 8 6 Girls Mean wt Mean + 2SD Mean - 2SD Girls WHO Wt Mean + 2SD Mean - 2SD 4 2 0 0 2 4 6 12 18 Age (mon)

Weight (kg) Growth in weight infants in Qatar vs CDC data 16 14 12 10 8 6 Boys Mean Wt Mean + 2SD Mean - 2SD CDC Mean Wt Mean + 2SD Mean - 2SD 4 2 0 0 2 4 6 12 18 Age (mon)

Weight (kg) Growth in weight Girls in Qatar vs CDC 16 14 12 10 8 6 Girls Mean wt Mean + 2SD Mean - 2SD CDC Mean wt Mean + 2SD Mean - 2SD 4 2 0 0 2 4 6 12 18 Age (mon)

Conclusion When WHO and CDC standards are compared, more infants were identified as overweight when the former were used. The WHO standards are preferable because they are based on a leaner breastfed reference and because overweight is likely to be a greater problem in Qatar in the future The WHO standards are preferable if the setting of health education is offered every visit.