TM Optimizing nutrition in stunted children: Interventions and practices Umaporn Suthutvoravut Faculty of Medicine Ramathibodi Hospital Mahidol University Outline Background information Nutrition intervention Practice in Thailand Conclusion 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
Classification Definition Grading Gomez (1956) Waterlow (1972) WHO (1983) (wasting) WHO (1983) (stunting) Definition of malnutrition Weight below 90% median WA Weight below 90% median WH WH Z-score below -2 HA Z-score below -2 Mild (grade 1) Moderate (grade 2) Severe (grade 3) Mild Moderate Severe Moderate Severe Moderate Severe 75%-90% WA 60%-74% WA <60% WA 80%-90% WH 70%-80% WH <70% WH -3 z-score <-2 z-score <-3-3 z-score <-2 z-score <-3 Severity Waterlow classification 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 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. Childhood stunting Often occurs in utero and extends through infancy and childhood Severe short-term and long-term health and functional consequences First 1,000 days of life At Birth 6 Yars Old 14 Years Old 2 months 5 months Newborn 2 years 6 years 12 years 25 years In uterus In uterus
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." Linear growth & child development in LMICs: Meta-analysis 68 studies in 29 low- and middle-income countries Cross-sectional and prospective studies Anthony Lake, Executive Director of UNICEF 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. Multivariate adjusted prospective SMD in cognition per unit increase in HAZ. + 0.24 + 0.22 + 0.09 Sudfeld CR et al. Pediatrics 2015; 135: e1266-75. Sudfeld CR et al. Pediatrics 2015; 135: e1266-75.
Maternal and child undernutrition: Consequences for adult health & human capital 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 40%reductionin the number of children under-5 who are stunted. Victora CG et al. Lancet 2008 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 Short-term consequences: Mortality, morbidity, disability Long-term consequences: Adult size, intellectual ability, economic productivity, reproductive performance, metabolic and cardiovascular disease Changes in stunting prevalence between 1996-2010 in SEA countries Inadequate dietary intake Maternal and child undernutrition Disease Immediate causes Household food insecurity Inadequate care Unhealthy household environment and lack of health services Underlying causes Income poverty: employment, selfemployment, dwelling, assets, remittances, pensions, transfers etc Lack of capital: financial, human, physical, social, and natural Social, economic, and political context Basic causes Black RE, et al. Lancet 2008. 32 36 44 17 35 30 0 16 19 Bloem MW et al. Food Nutr Bull 2013;34:S8-16. Globalnutritionreport.org 2015
Stunting rates by Gross Domestic Product in selected ASEAN countries: 2010 data Energy Protein Optimal catch-up growth Treat causes Micronutrients Bloem MW et al. Food Nutr Bull 2013;34:S8-16. Energy & protein requirement to catch up 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 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 Protein and bone growth Growth hormone, zinc *Insulin-like growth factor-1 Amino acids IGF-1* Bone growth Stimulate chondrocyte & osteoblast Intestinal Ca, P absorption 25(OH)D 3 1,25(OH) 2 D 3 Renal tubular P absorption
Dietary protein Major nutrients for bone growth Renal tubular Ca reabsorption Endogenous acid production Cellmediated bone resorption Direct physicochemical dissolution of bone Protein & Energy Vitamins: D, K, A, C Minerals: Ca, P, Mg, Na, K Urinary calcium loss I, Zn, Cu, Fe, F Bone loss 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 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 Hans de Beer. Economics & Human Biology 2012. Dairy products and physical stature Additional growth of 0.4 cm/year/245 ml of milk daily 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. 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 23 LM 29 LM 125 ml milk 42 250 ml milk+sandwich 21 Yoghurt 15 4 Middle age, 45-60 70 Milk 57 64 Sirichakwal PP, et al. 1989-2002 40 Low lactose milk 17 36 40 Lactose-free milk 11 6
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 Zinc supplementation and linear growth: Meta-analysis of RCT 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 ZnSO 4 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 No effect of iron intervention on height 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 Brown KH et al. Am J Clin Nutr 2002. Vucic V et al. Nutr Rev 2013. Strategies for prevention and control of malnutrition in Thailand Food & Nutrients Public health &Community Regulation& Education Food/micronutrient supplementation Food fortification Food security Public health measures: immunization, sanitation, water supply, deworming, growth monitoring, etc Community-based approaches Food regulation Food and nutrition education/communication Capacity building, Research & Development 36 Food fortification and Food-based Dietary Guidelines in Thailand 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-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 schoolage 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 Conclusion 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