Growth and Body Composition 5 y After Treatment for Severe Acute Malnutrition: A 5-y Prospective Matched Cohort Study in Ethiopian Children

Associations of early childhood exposure to severe acute malnutrition and recovery with cardiometabolic risk markers in later childhood: 5-year prospective matched cohort study in Ethiopia

BACKGROUND

Impaired fetal and accelerated postnatal growth are associated with cardiometabolic disease. Few studies investigated how recovery from severe acute malnutrition (SAM) is associated with childhood cardiometabolic risk.

OBJECTIVES

We evaluated cardiometabolic risk in children with SAM treated through community-based management, relative to controls, 5-y postrecovery. Recognizing the heterogeneity of SAM case definitions and patterns of nutritional recovery, we also identified distinct body mass index-for-age z-score (BAZ) trajectories of children with SAM in the first year postrecovery and examined their associations with anthropometry, body composition, and cardiometabolic risk markers, relative to controls, 5-y postrecovery.

METHODS

A prospective cohort study in 2013 enrolled children aged 6-59 mo, recovered from SAM (n = 203), or nonwasted controls (n = 202), in Jimma Zone, Ethiopia. Anthropometry, body composition, and cardiometabolic markers were assessed 5 y postrecovery. Multiple linear regression models compared outcomes between SAM-recovered children and controls. We used latent class trajectory modeling to identify BAZ trajectories in the first year postrecovery and compared these trajectory groups with controls.

RESULTS

We traced 291 (71.9%) children (mean age 6.2 y) at 5-y follow-up. Overall, compared with controls, SAM-recovered children did not differ in cardiometabolic risk. We identified 4 BAZ trajectories among SAM-recovered children: "increase" (74.6%), "decrease" (11.0%), "decrease-increase" (5.0%), and "increase-decrease" (9.4%). Compared with controls, all BAZ trajectories except "decrease-increase" had lower weight, height, and fat-free mass index. Compared with controls, the "decrease-increase" trajectory had lower glucose [-15.8 mg/dL; 95% confidence interval (CI): -31.2, -0.4], whereas the "increase-decrease" trajectory had higher glucose (8.1 mg/dL; 95% CI: -0.8, 16.9). Compared with controls, the "decrease-increase" and "decrease" trajectories had higher total cholesterol (24.3 mg/dL; 95% CI: -9.4, 58.4) and low-density lipoprotein cholesterol (10.4 mg/dL; 95% CI: -3.8, 24.7), respectively. The "increase" trajectory had the lowest cardiometabolic risk.

CONCLUSIONS

Both rapid BAZ increase and decrease during early postrecovery from SAM were associated with greater cardiometabolic risk 5 y later. The findings indicate the need to target postrecovery interventions to optimize healthy weight recovery.

Correlates of Body Composition in Children with Stunting: A Cross-sectional Study in Uganda

BACKGROUND

Development of body composition (BC) may be disrupted in children with stunting. Such disruption may affect the later risk of excess adiposity and metabolic health, yet few studies have investigated correlates of BC in children with stunting.

OBJECTIVES

We aimed to investigate nutritional status, infection and inflammation, breastfeeding behaviors, and other factors as correlates of BC in children with stunting.

METHODS

Among Ugandan children with a height-for-age z-score <-2, BC was estimated using bioelectrical impedance analysis and compared with United Kingdom references. We used multiple linear regression analysis to identify correlates of fat mass (FM), fat-free mass (FFM), FM-index (FMI), and FFM index (FFMI) and height, adjusting for gender and age.

RESULTS

In 750 children aged 1-5 y, FMI was 0.46 (95% confidence interval [CI]: 0.38, 0.54] and FFMI 0.18 [95% CI: 0.11, 0.26) z-scores lower than United Kingdom references. Elevated serum α1-acid glycoprotein was associated with 1.14 [0.76, 1.52] cm lower height, 0.50 [0.35, 0.65] kg/m2 less FFMI, and 0.48 [0.31, 0.66] kg/m2 greater FMI. Similar, weaker, associations for elevated serum C-reactive protein were detected. A positive malaria rapid test was associated with 0.64 [0.25, 1.02] cm shorter height, but 0.36 [0.18, 0.54] kg/m2 greater FMI. Anemia (according to hemoglobin) was associated with 0.20 [0.07, 0.33] kg less FFM in proportion to shorter height. Longer breastfeeding duration was associated with 0.03 [0.02, 0.04] kg greater FFM per month, in proportion to greater height.

CONCLUSIONS

These children exhibited deficits in FM and FFM, proportionally to their stunted height, compared with United Kingdom references. Systemic inflammation correlated inversely with linear growth and FFM but positively with fatness, making it a possible target for intervention where fat-free tissue accretion is desirable. Longer breastfeeding may offer protection to lean linear growth, but findings for micronutrients were less clear. Longitudinal studies are warranted to support these findings. The study was registered at www.isrctn.com (Ref. ISRCTN13093195).

The recent WHO guideline on acute malnutrition overestimates therapeutic energy requirement

The World Health Organization has recently updated the guideline on the prevention and management of wasting and nutritional oedema (acute malnutrition) in infants and children under 5 years. Apart from differences with regard to the nutritional framework that defines the quantity of energy required as Ready-to-Use Therapeutic Food (RUTF) for the outpatient treatment of severe wasting and/or nutritional oedema, there are also important gaps in the practical guidance. Instead of the recommended energy intake of 150-185 kcal/kg/day, our alternative calculations indicate the requirement to be only 105-120 kcal/kg/day. If true, the implementation of such caloric overfeeding can have adverse consequences. Gaps in practical guidance also need to be addressed, including the timing of transition to home-based diets, maximal duration of therapeutic feeding, especially in non-responders (∼50% in South Asia), and the role of augmented home foods as the primary therapeutic food option.