IPA RECOMMENDATIONS FOR UNDER/ OVERWEIGHTAS PART OF PEDIATRIC MALNUTRITION IN LOW- AND MIDDLE- INCOME COUNTRIES. An individual approach complementary to the actions of the WHO ‘Commission on ending childhood obesity’
Manuel Moya.
Professor Emeritus of Pediatrics. Chair of the Technical Advisory Group on Nutrition of theInternational Pediatric Association
DESCRIPTION / RATIONALE
In low- and middle-income countries (LMIC) with a predominance of undernutrition, enhanced weight gain in children is a desirable aim due to the fact of reduced morbidity and mortality and better cognitive development. But it might carry an increased risk for later obesity when it occurs in the first two years of age (1) and consequently for the well-known clinical burden that the comorbidities imply (2 Moya) already present in pediatric ages. This is an important issue according to the next epidemiological studies analysis. The advantagesof this program lie on its dual capacityfor assessing over and underweight in a determined pediatric population once the somatometric measurements are taken. Prevalence at early ages and subsequent and feasible nutritional changes are indicated. Early identification of overweight (plus other risk factors)is the corner stone of preventive efficiency.
In the past decade Khor (3) described in Malaysia the dual forms of malnutrition when underweight and overweight coexisted in different groups of a population and also this dual form of malnutrition in the same household. Ten years later (4 Ihab) in the same country, this dual coexistence but in rural areas is described,and the same occurs in Indonesia, where 16 % of Indonesian households are identified as dual burden (5, Roemling). This situation can be an important challenge for food intervention programs that are leading to overweight as intra-household studies show.
Growing frequency. Figures are widely varied probably because of different country nutritional level, different ages and gender of the studied populations but also for the different methods of assessment. In data from five developing countries (6, Gupta) the frequency of overweight in the 5-19 age year segment was >15 % with an increasing secular trend of 5 years. In data from a part of Iran (7, Fatemeh) a frequency of overweight of 10.6 % was found in children of 2-5 years old. In Brazil (8, Nascimento) the frequency of overweight was of 28.8 % in preschools of 2-3 years old. In northeast India (9, Sikdar) the prevalence of underweight was of 17.2-27.7 % in boys, while overweight being of 2.0- 7.8 %. In Malaysia (4, Ihab) underweight (and stunting) was of 61.0 %, whereas overweight was 35.0 % in their mothers. In a large urban study in southwest China (10, Li) underweight was 6.3 % and overweight 17.8 %. Global, regional and country levels and trends have been confirmed this coexistence but with an important growth of overweight more recently (11 Unicef). This varied panorama gives a less inaccurate image of this coexistence or dual burden of malnutrition, but clearly points out its existence.
To end this extract it is necessary to quote the work of COHORTS group, led by Linda S Adair (12, Adair). In a carefully designed prospective study going from birth to adulthood tracking 8362 participants from 5 low-income countries their conclusions are: a higher birthweight was associated with a greater adult BMI (> 25 kg/m2). Faster linear growth in the first two years was strongly associated with a lower risk of short adult stature but also with the likelihood of overweight and some comorbidities. Faster relative weight gain in the same period was linked to an increased risk of adult overweight and comorbidities. The same three issues occur when they considered mid-childhood segment although odds ratios were slightly lower. We can summarize this dual problem stating that the approach of underweight must not be neglected but the care of this situation should take into account the risk of developing overweight in children and later on adults.
To end this rationale three points should be considered: a) the WHO Draft action plan for the prevention and control of non-communicable diseases 2013-2020 which has an important dedication to obesity prevention in the nutrition section (13 WHO). b) in underweight it is important to assess the inadequate intake of essential nutrients (14 Biesalski), and c) Prevention initiated at pediatric ages is more efficient (15 Moya).
Aim: to assess the nutritional status and a rough assessment of vitamin A , calcium and iron intake in a pediatric population of the low income countries.
METHODS
Body mass index (BMI) expressed as kg/m2 is the basic measure of the body shape (16, Koen) i.e. ‘thickness, thinness’ then the terms under/ overweight will be used as their numerical measurement base. It is well known that the crude figures of kg/m2 so useful in adults do not prove so in pediatric ages because they change substantially with age. In normal circumstances they are: 13 kg/m2 at birth; 17 kg/m2 at 1 yr. ; 15.5 kg/m2 at 6 yr. ; 21 kg/m2 at 20 yr. Consequently a series of cut off lines for underweight and overweight are required for the whole period of pediatric age and gender. If percentiles are different in different countries and their quantitation implies normally a certain degree of subjectivity, the Z-score cut off point of +/- 2SD appears as the most appropriate method, although not always accessible in LMIC. Due to the fact that Cole et al have obtained these cut off lines that will continue with the accepted limits for adults of 25 kg/m2 for overweight and 30 kg/m2 for obesity (17, Cole) and 17 kg/m2 for thinness or underweight or WHO grade 2 and 16 kg/m2 for undernourished (18 Cole). These reference values are going to be used (Figure 1) for assessing under/overweight in the studied population.
In order to assess the degree of under/ overweight the first point is to accurately measure the height, weight and waist circumference. The simple device that hangs on a wall and its reader slides down to the head has a negligible cost and is accurate enough. Once the height and weight are obtained the BMI (kg/m2) is easy to get by means of the most elementary calculator (even the one in a mobile) dividing the weight in kilos by the height in metres and again by the height in metres. If for example a 4 year and three months old boy has a BMI of 18.9 kg/m2, in Table 1 it can be seen that his age is closer to the 4.5 year, if moving to the wright along this line it can be found that the nearest figure to his BMI is 19.3 kg/m2 which is in the furthest column (obesity). This procedure allows to initially classifying the population as undernourished, underweight, overweight and obese because as said the Cole studies show that these columns will continue with BMI of 16, 17, 18.5, 25 and 30 kg/m2 that classify the nutritional status of adults well recognized after data out from different world regions. After this screening an initial nutritional assessment can be obtained requiring further confirmation (BMI-Zs, WC…) even including the last 24 hours food intake record (Figure 1). This method avoids the use of varied or local growth charts if available and with only two tables (boys and girls) which remain at the health point it is possible to assess the present and future nutritional situationwith a reliable precision.
An effort should be made for measuring the height and weight of mothers and calculate their BMI (kg/m2) due to the important relationship of maternal overweight and obesity and birthweight (19 Tyrrell) and subsequent obesity predisposition of the offspring.
Sample size (minimum) . Considering an expected prevalence of normal weight (w situation), a confidence level of 95% and a statistical precision of 5%, the sample size needed in each studied country would be of 350 subjects. Pediatric health centres located in big cities from Africa, South Asia, Latin America, Europe and Middle East can be identified and incorporated into this survey.
The number of participants (children & mothers), 1400 pairs are high but necessary in order to have informative data.
A simple email training program for health professionals has been planned (instruction for correct body measurements, 24 hr. food questionnaire and nutritional advice)
Kids with no major disease from both gender and from 2-5 yr. will be included and the health professional will fill the one sheet form (Figure 2) with basic data for evaluating the nutritional status. The completed forms will be sent to the designed board in order to process statistically the obtained data. The calculation of the z-score value can be done though the ‘BMI and Z-score Calculator’ of Children’s Hospital of Philadelphia (www. Stokes.Chop.edu/web/zscore/result.php), or through the Seinaptracker program.
BUDGET.
Required material: Height meter screwed to wall (~10 €), digital scales (~50 €), unextensible tape measure (~3 €) and a basic calculator (10 €).
A material incentive for field work could be considered.
PROGRAM OUTCOMES.
The present phase is merely descriptive although an advisory simple plan will be given to the mother in case of under/overweight.
The long-term effect will be based (2nd phase) primarily on the health professional’s education, the mother’s education and in information to the National Health Authorities.
The effectiveness should be measured in a longer period of time (> 4 yr)
The program requires very little training) hence it can be started after one month. The duration is 2 yr. for phase 1.
The nutrition board of IPA could design 3 officers for collecting new data.
REFERENCES
- Stettler N, Iotova V. Early growth patterns and long-term obesity risk. Curr Opin Clin Nutr Metab Care 2010; 13: 294-9.
- Moya M. Hidden comorbidities present in obese children and adolescent. EPA Newsletter Mar 2013; 5(17): 4-7. 18
- Khor GL, Sharif ZM. Dual forms of malnutrition in the same households in Malaysia- a case study among Malay rural households. Asia Pacific J clin Nutr 2003; 12: 427-38.
- Ihab AN, Rohana AJ, Manan WM, Suriati WN, Zalilah MS, Rusli AM. The coexistence of dual form of malnutrition in a sample of rural Malaysia. Int J Prev Med 2013; 4(6): 690-9.
- Roemling C, Qaim M. Dual burden households and intra-households nutritional inequality in Indonesia. Econ Hum Biol 2013. Doi 10. 1016/ j. ehb 20.07.001
- Gupta N, Shah P, Nayyar S, Misra A. Childhood obesity and the metabolic syndrome in developing countries. Indian J Pediatr 2013; 80 Supp1: S28-37.
- Fatemeh T, Mohammad-Mehdi HT, Toba K, Afsaneh N, Sharifzadeh G. Prevalence of overweight and obesity in preschool children (2-5 year-old) in Birjand Iran. BMC Research Notes 2012; Sep 25; 5: 529. DOI 10. 1186/ 1756- 0500-5-529.
- Nascimento VG, Silva JP, Bertoli CJ, Abreu LC, Valenti VE, Leone C. Prevalence of overweight preschool children in public day care centers: a cross-sectional study. Sao Paulo Med J. 2012; 130: 225-9.
- Sikdar M. Prevalence of malnutrition among the mising children of northeast India: a comparison between four different sets of criteria. N Am J Med Sci. 2012 Jul 4(7) :305-9. Doi10.41103/1947-2714.98589.
- Li P, Yang F, Xiong F, Huo T, Tong Y, Yang S. Nutritional status and risk factors of overweight and obesity for children aged 9-15 years in Chengdu, southwest China. BMC Public Health 2012 Aug 10; 12: 636. Doi 10. 1186/ 1471-2458-12-636.
- UNICEF-WHO-World Bank. Level and trends in child malnutrition. Key findings of the 2015 edition. Ini.cf/jmedashboard2015.
- Adair LS, Fall CHD, Osmond C, Stein AD, Martorell R, Ramirez-Zea M. Association of linear growth and relative weight gain during early life with adult health and human capital in countries of low and middle income: findings from five birth cohorts studies.. Lancet 2013; 382: 525-34.
- WHO. Draft action for the prevention and control of noncommunicable dseases. (22April 2013.
- Biesalski HK. Meeting Report International Congress ‘Hidden Hunger’. Ann Nutr Metab 2013; 62: 298-302.
- . Moya M. An update in prevention and treatment of pediatric obesity. World J Pediatr 2008; 4 (3): 173-185.
- Joosten KFM, Hulst JM. Malnutrition in pediatric hospital patients: Current issues. Nutrition 2011; 27: 133-7
- Cole TJ, Bellizy MC, Flegal M, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000; 320: 1-4.
- Cole TJ, Flegal KM, Nicholls D, Jackson AA. Body mass index cut offs to define thinness in children and adolescents: international survey. BMJ 2007; 335: 194- 206.
- Tyrrell J and the Early Growth Genetics Consortium. JAMA 2016; 315: 1129-40.
PEDIATRIC UNDER/OVERWEIGHT IN LOWER-INCOME AREAS
Individual clinical data form
Country/City______Observation number______
CHILD DATA MAIN DIAGNOSES______
Name:______Date of birth:______Date:______
Height (cm):______Weight (kg):______Head circ (cm):____Arm circ (cm):______
BP (mmHg)------/------BMI:______kg/m2
Last 24 hrs record (accurate description please);
Breakfast:Time:______
Main meal:Time:______
Any other light food:Time:______
Last meal of day:Time:______
Does he/she normally eat between meals? Yes/NoWhat?______
Does he/she eat sweets or occidentalised food? Yes/No
Does he/she drink soft drinks? Yes/No
MOTHER DATA
Height (cm)______Weight (kg)______BMI______kg/m2
Number of offspring:______
REMARKS:
BOYS
UNDER/ OVERNUTRITION EVALUATION (Cole)
AGE (y) / UN / UW / NORMO / OW / OB2.0 / 13.4 / 14.1 / 15.1 / 18.4 / 20.1
2.5 / 13.2 / 13.9 / 14.9 / 18.1 / 19.8
3.0 / 13.1 / 13.8 / 14.7 / 17.9 / 19.8
3.5 / 13.0 / 13.6 / 14.6 / 17.7 / 19.4
4.0 / 12.9 / 13.5 / 14.4 / 17.6 / 19.3
4.5 / 12.7 / 13.4 / 14.3 / 17.5 / 19.3
5.0 / 12.7 / 13.3 / 14.2 / 17.5 / 19.2
5.5 / 12.6 / 13.2 / 14.1 / 17.5 / 19.3
6.0 / 12.5 / 13.2 / 14.1 / 17.6 / 19.8
6.5 / 12.5 / 13.1 / 14.0 / 17.7 / 20.2
7.0 / 12.4 / 13.1 / 14.0 / 17.9 / 20.6
7.5 / 12.4 / 13.1 / 14.1 / 18.2 / 21.1
8.0 / 12.4 / 13.1 / 14.2 / 18.4 / 21.6
8.5 / 12.5 / 13.2 / 14.2 / 18.8 / 22.2
9.0 / 12.5 / 13.2 / 14.4 / 19.1 / 22.8
9.5 / 12.6 / 13.3 / 14.5 / 19.5 / 23.4
10.0 / 12.7 / 13.5 / 14.6 / 19.8 / 24.0
10.5 / 12.8 / 13.6 / 14.8 / 20.2 / 24.6
11.0 / 12.9 / 13.7 / 15.0 / 20.6 / 25.1
11.5 / 13.0 / 13.9 / 15.2 / 20.9 / 25.6
12.0 / 13.2 / 14.1 / 15.4 / 21.2 / 26.0
12.5 / 13.4 / 14.3 / 15.6 / 21.6 / 26.4
13.0 / 13.6 / 14.5 / 15.8 / 21.9 / 26.8
13.5 / 13.8 / 14.7 / 16.1 / 22.3 / 27.3
14.0 / 14.1 / 15.0 / 16.4 / 22.6 / 27.6
14.5 / 14.4 / 15.3 / 16.7 / 23.0 / 28.0
15.0 / 14.6 / 15.6 / 17.0 / 23.3 / 28.3
15.5 / 14.9 / 15.8 / 17.3 / 23.6 / 28.6
16.0 / 15.1 / 16.1 / 17.5 / 23.9 / 28.9
16.5 / 15.4 / 16.3 / 17.8 / 24.2 / 29.1
17.0 / 15.6 / 16.6 / 18.1 / 24.5 / 29.4
17.5 / 15.8 / 16.8 / 18.3 / 24.7 / 29.7
18 / 16.0 / 17.0 / 18.5 / 25.0 / 30.0
UN: Undernourished
UW: Underweight
Normo: Normoweight
OW: Overweight
OB: Obesity
BMI =Kg/m2
Cole TJ et al.
BMJ 2000; 320:1
Cole TJ et al.
BMJ 2007; 335:194
GIRLS
UNDER/ OVERNUTRITION EVALUATION (Cole)
AGE (y) / UN / UW / NORMO / OW / OB2.0 / 13.2 / 13.9 / 14.8 / 18.0 / 19.8
2.5 / 13.1 / 13.7 / 14.6 / 17.8 / 19.6
3.0 / 13.0 / 13.6 / 14.5 / 17.6 / 19.4
3.5 / 12.9 / 13.5 / 14.3 / 17.4 / 19.2
4.0 / 12.7 / 13.3 / 14.1 / 17.3 / 19.2
4.5 / 12.6 / 13.2 / 14.1 / 17.2 / 19.1
5.0 / 12.5 / 13.1 / 13.9 / 17.2 / 19.2
5.5 / 12.4 / 13.0 / 13.9 / 17.2 / 19.3
6.0 / 12.3 / 12.9 / 13.8 / 17.3 / 19.7
6.5 / 12.3 / 12.9 / 13.8 / 17.5 / 20.1
7.0 / 12.3 / 12.9 / 13.9 / 17.8 / 20.5
7.5 / 12.3 / 13.0 / 13.9 / 18.0 / 21.0
8.0 / 12.3 / 13.0 / 14.0 / 18.4 / 21.6
8.5 / 12.4 / 13.1 / 14.1 / 18.7 / 22.2
9.0 / 12.4 / 13.2 / 14.3 / 19.1 / 22.8
9.5 / 12.5 / 13.3 / 14.4 / 19.5 / 23.5
10.0 / 12.6 / 13.4 / 14.6 / 19.9 / 24.1
10.5 / 12.8 / 13.6 / 14.8 / 20.3 / 24.8
11.0 / 13.0 / 13.8 / 15.0 / 20.7 / 25.4
11.5 / 13.2 / 14.0 / 15.3 / 21.2 / 26.1
12.0 / 13.4 / 14.3 / 15.6 / 21.7 / 26.7
12.5 / 13.7 / 14.6 / 15.9 / 22.1 / 27.2
13.0 / 13.9 / 14.8 / 16.3 / 22.6 / 27.8
13.5 / 14.2 / 15.1 / 16.6 / 23.0 / 28.2
14.0 / 14.5 / 15.5 / 16.9 / 23.3 / 28.6
14.5 / 14.8 / 15.7 / 17.2 / 23.7 / 28.9
15.0 / 15.0 / 16.0 / 17.5 / 23.9 / 29.1
15.5 / 15.3 / 16.2 / 17.7 / 24.2 / 29.3
16.0 / 15.5 / 16.4 / 17.9 / 24.4 / 29.4
16.5 / 15.6 / 16.6 / 18.1 / 24.5 / 29.6
17.0 / 15.8 / 16.8 / 18.3 / 24.7 / 29.7
17.5 / 15.9 / 16.9 / 18.4 / 24.9 / 29.8
18.0 / 16.0 / 17.0 / 18.5 / 25.0 / 30.0
UN: Undernourished
UW: Underweight
Normo: Normoweight
OW: Overweight
OB: Obesity
BMI =Kg/m2
Cole TJ et al.
BMJ 2000; 320:1
Cole TJ et al.
BMJ 2007; 335:194