Child stunting concurrent with wasting or being overweight: A 6-y follow up of a randomized maternal education trial in Uganda

8-Year Follow-up of a Maternal Education Trial in a Low-Resource Setting

OBJECTIVES

Nutrition and stimulation interventions promote early childhood development, but little is known about their long-term benefits in low- and middle-income countries. We conducted a follow-up study of a cluster-randomized maternal education trial performed in children aged 6 to 8 months to assess the sustainability of developmental benefits after 8 years.

METHODS

The education intervention lasted 6 months and consisted of nutrition, hygiene, sanitation, and child stimulation aspects. We assessed child processing and cognitive abilities using the Kaufman Assessment Battery for Children Second Edition (KABC-II) and attention and inhibitory control using the Test of Variables of Attention after 8 years. The original trial included 511 mother-child pairs (intervention, n = 263; control, n = 248), whereas in the current study, 361 (71%; intervention, n = 185; control, n = 176) pairs were available for analyses.

RESULTS

The intervention group scored higher than the controls (all P < .001) on all 5 KABC-II subscales and on the KABC-II global score (mean difference: 14; 95% confidence interval, 12-16; P < .001). For all 5 Test of Variables of Attention variables, the intervention group scored higher than the controls on both the visual and auditory tasks (all P < .05). Because the intervention was delivered as a package, a limitation is that we cannot pinpoint the individual contribution of each component (nutrition, hygiene, and stimulation) to the developmental benefits.

CONCLUSIONS

The intervention group consistently scored markedly higher on both neuropsychological tests. Thus, even 8 years after the original maternal education intervention, the developmental benefits that we observed at child age of 1, 2, and 3 years, were sustained.

The effect of nutrition-specific and nutrition-sensitive interventions on the double burden of malnutrition in low-income and middle-income countries: a systematic review

BACKGROUND

Low-income and middle-income countries (LMICs) experiencing nutrition transition face an increasing double burden of malnutrition (DBM). WHO has urged the identification of risks and opportunities in nutrition interventions to mitigate the DBM, but robust evidence is missing. This review summarises the effect of nutrition-specific and nutrition-sensitive interventions on undernutrition and overnutrition in LMICs.

METHODS

We searched four major databases and grey literature for publications in English, French, Portuguese, and Spanish from Jan 1, 2000, to Aug 14, 2023. Eligible studies evaluated nutrition-specific or nutrition-sensitive interventions on both undernutrition and overnutrition, employing robust study designs (individually randomised, cluster randomised, and non-randomised trials; interrupted time series; controlled before-after; and prospective cohort studies). Studies were synthesised narratively, and classified as DBM-beneficial, potentially DBM-beneficial, DBM-neutral, potentially DBM-harmful, and DBM-harmful, using vote counting. This review is registered with PROSPERO (CRD42022320131).

FINDINGS

We identified 26 studies evaluating 20 nutrition-specific (maternal and child health [MCH] and school-based programmes) and six nutrition-sensitive (conditional cash transfers and other social policies) interventions. Seven of eight MCH interventions providing food-based or nutritional supplements indicated possible DBM-harmful effects, associated with increased maternal or child overweight. Most school-based programmes and MCH interventions that target behavioural change were considered potentially DBM-beneficial. Two studies of conditional cash transfers suggested DBM-beneficial effects in children, whereas one indicated potentially harmful effects on maternal overweight. A study on a family planning service and one on an education reform revealed possible long-term harmful effects on obesity.

INTERPRETATION

There is considerable scope to repurpose existing nutrition interventions to reduce the growing burden of the DBM in LMICs. In settings undergoing rapid nutrition transition, specific policy attention is required to ensure that food-based or supplement-based MCH programmes do not unintentionally increase maternal or child overweight. Consistent reporting of undernutrition and overnutrition outcomes in all nutrition interventions is essential to expand the evidence base to identify and promote interventions maximising benefits and minimising harms on the DBM.

FUNDING

President's Scholarship (Imperial College London) and National Institute for Health and Care Research.

TRANSLATIONS

For the Portuguese, Spanish and French translations of the abstract see Supplementary Materials section.

Child wasting and concurrent stunting in low- and middle-income countries

Sustainable Development Goal 2.2-to end malnutrition by 2030-includes the elimination of child wasting, defined as a weight-for-length z-score that is more than two standard deviations below the median of the World Health Organization standards for child growth1. Prevailing methods to measure wasting rely on cross-sectional surveys that cannot measure onset, recovery and persistence-key features that inform preventive interventions and estimates of disease burden. Here we analyse 21 longitudinal cohorts and show that wasting is a highly dynamic process of onset and recovery, with incidence peaking between birth and 3 months. Many more children experience an episode of wasting at some point during their first 24 months than prevalent cases at a single point in time suggest. For example, at the age of 24 months, 5.6% of children were wasted, but by the same age (24 months), 29.2% of children had experienced at least one wasting episode and 10.0% had experienced two or more episodes. Children who were wasted before the age of 6 months had a faster recovery and shorter episodes than did children who were wasted at older ages; however, early wasting increased the risk of later growth faltering, including concurrent wasting and stunting (low length-for-age z-score), and thus increased the risk of mortality. In diverse populations with high seasonal rainfall, the population average weight-for-length z-score varied substantially (more than 0.5 z in some cohorts), with the lowest mean z-scores occurring during the rainiest months; this indicates that seasonally targeted interventions could be considered. Our results show the importance of establishing interventions to prevent wasting from birth to the age of 6 months, probably through improved maternal nutrition, to complement current programmes that focus on children aged 6-59 months.

The coexistence of stunting and overweight or obesity in Ethiopian children: prevalence, trends and associated factors

BACKGROUND

Double burden of childhood malnutrition is a condition where undernutrition (stunting) along with overweight and obesity coexist within individuals, households, and populations. It reflects a new layer of malnutrition and an understudied phenomenon in many low-income settings. To date, the prevalence and factors that are associated with concurrent stunting and overweight or obesity (overweight/obesity) (CSO) in the same children have not been well researched in Ethiopia. Hence, this study aimed to assess the prevalence, trends, and factors associated with the coexistence of stunting and overweight or obesity among children aged 0-59 months in Ethiopia.

METHODS

Pooled data from 2005, 2011 and 2016 Ethiopian Demographic and Health Survey (EDHS) were used. A total of 23,756 (weighted sample) children aged 0-59 months were included in the study. Height-for-age z-scores (HAZ) less than - 2 SD and weight-for-height z-scores (WHZ) above 2 SD were calculated, and children were classified as stunted and overweight/obese, respectively. A child who is simultaneously stunted and overweight/obese was considered as having HAZ below - 2 SD and WHZ above 2 SD computed into a variable named CSO, and reported as a binary outcome (yes or no). Multilevel logistic regression analysis that adjusts for sampling weights and clustering was used to identify factors associated with CSO.

RESULTS

The prevalence of stunting, overweight or obesity, and CSO among under-five children was 43.12% [95% CI: (42.50, 43.75%)], 2.62% [95% CI: (2.42, 2.83%)], and 1.33% [95% CI: (1.18, 1.48%)], respectively. The percentage of CSO children was reported to have declined from 2.36% [95% CI: (1.94-2.85)] in 2005 to 0.87% [95%CI: (0.07-1.07)] in 2011, and the same appeared to have increased slightly to 1.34% [95%CI: (1.13-1.59)] in 2016. Children who were currently breastfeeding [AOR: 1.64, 95%CI: (1.01-2.72)], born to an overweight mother [AOR: 2.65, 95%CI: (1.19-5.88)], and lived in families with 1-4 household members [AOR: 1.52, 95%CI: (1.02-2.26)] were significantly associated with CSO. At the community level the odds of having CSO were higher among children included from EDHS-2005 [AOR: 4.38, 95%CI: (2.42-7.95)].

CONCLUSION

The study revealed that less than 2% of children had CSO in Ethiopia. CSO was linked to factors at both the individual (i.e. breastfeeding status, maternal overweight, and household size) and community-levels. Overall, the study findings indicated the necessity of focused interventions to simultaneously address double burden of childhood malnutrition in Ethiopia. To further combat the double burden of malnutrition, early identification of at-risk children, including those born to overweight women and children living with multiple household members, is indispensable.

Nutritional inequalities among under-five children: a geospatial analysis of hotspots and cold spots in 73 low- and middle-income countries

Background

Child undernutrition is a severe health problem in the developing world, which affects children’s development in the long term. This study analyses the extent and patterns of under-five child undernutrition using Demographic and Health Surveys (DHS) for 73 low- and middle-income countries (LMICs).

Methods

First, we mapped the prevalence of undernutrition in the developing world. Second, using the LISA (a local indicator of spatial association) technique, we analyzed the geographical patterns in undernutrition to highlight the localized hotspots (regions with high undernutrition prevalence surrounded by similar other regions), cold spots (regions with low undernutrition prevalence surrounded by similar other regions), and outliers (regions with high undernutrition surrounded by low undernutrition and vice versa). Third, we used Moran’s I to find global patterns in child undernutrition.

Results

We find that South Asia has the highest under-five child undernutrition rates. The intra-country nutritional inequalities are highest in Burundi (stunting), Kenya (wasting), and Madagascar (underweight). The local indicator of spatial association (LISA) analysis suggests that South Asia, Middle East and North Africa (MENA) region, and Sub-Saharan Africa are undernutrition hotspots and Europe and Central Asia and Latin America, and the Caribbean are undernutrition cold spots (regions with low undernutrition surrounded by similar other regions). Getis Ord-Gi* estimates generally support LISA analysis. Moran’s I and Geary’s C gave similar results about the global patterns of undernutrition. Geographically weighted regressions suggest that several socioeconomic indicators significantly explain child undernutrition.

Conclusions

We found a significant within and across country variation in stunting, wasting and underweight rates among the under-five children’s population. The geospatial analysis also suggested that stunting, wasting, and underweight patterns exhibit clear regional patterns, underscoring the need for coordinated interventions at the regional level.

Malnutrition among hospitalized children 12-59 months of age in Abyan and Lahj Governorates / Yemen

BACKGROUND

The analysis of acute malnutrition in 2018 for the Integrated Phase Classification of Food Security in Yemen shows that high malnutrition rates are present in Abyan governorate (23%) and Lahj governorate (21%). This analysis was community based addressed all children and mostly due to problems related to food intake. The role of diseases was not yet addressed in Yemen. The aim of this study is to assess acute and chronic malnutrition among hospitalized children at 12-59 months of age in Lahj and Abyan governorates in Yemen.

METHODOLOGY

A cross-sectional, multi-center study is designed. The assessment of the nutritional status was measured by standardized anthropometry of 951 sick children at 12-59 months of age.

RESULTS

The prevalence of Global acute malnutrition (GAM) among the sick children seeking care in health facilities in Lahj and Abyan is 21%. More specifically; the prevalence of moderate acute malnutrition (MAM) is 15.1% while the prevalence of severe acute malnutrition (SAM) is 6.2%. The prevalence of acute malnutrition (wasting) among the studied sick children in lahj is 23.4% while in Abyan is 19.3%. The prevalence of MAM in Lahj is 17.7% and the prevalence of SAM is 5.7%. The prevalence of acute malnutrition (wasting) in Abyan is 12.6% while the prevalence of SAM in Abyan is 6.7%. The prevalence of acute malnutrition among male children (25.2%) is significantly higher than among female children (17.5%). The prevalence of the chronic malnutrition (Stunting) in the studied sick children is 41.3%; the prevalence of stunting in Lahj is 41% while in Abyan is 41.7%.

CONCLUSIONS

High acute and chronic malnutrition rates were identified among sick children seeking care in health facilities in lahj and Abyan, and higher than the SPHERE indicators of malnutrition. Boys are more exposed than girls to acute and chronic malnutrition.

Longitudinal assessments of child growth: A six-year follow-up of a cluster-randomized maternal education trial

Background & aims

Child growth impairments are rampant in sub-Saharan Africa. To combat this important health problem, long-term follow-up studies are needed to examine possible benefits and sustainability of various interventions designed to correct inadequate child growth. Our aim was to perform a follow-up study of children aged 60−72 months whose mothers participated in a two-armed cluster-randomized education intervention trial lasting 6 months in rural Uganda when their children were 6−8 months old with data collection at 20−24 and at 36 months. The education focused on nutrition, hygiene, and child stimulation.

Methods

We measured growth using anthropometry converted to z-scores according to WHO guidelines. We also included assessments of body composition using bioimpedance. We used multilevel mixed effect linear regression models with maximum likelihood method, unstructured variance-covariance structure, and the cluster as a random effect component to compare data from the intervention (receiving the education and routine health care) with the control group (receiving only routine health care).

Results

Of the 511 children included in the original trial, data from 166/263 (63%) and 141/248 (57%) of the children in the intervention and control group, respectively, were available for the current follow-up study. We found no significant differences in any anthropometrical z-score between the two study groups at child age of 60−72 months, except that children in the intervention group had lower (P = 0.006) weight-for-height z-score than the controls. There were no significant differences in the trajectories of z-scores or height growth velocity (cm/year) from baseline (start of original trial) to child age of 60−72 months. Neither did we detect any significant difference between the intervention and control group regarding body composition (fat mass, fat free mass, and total body water) at child age 60−72 months. Separate gender analyses had no significant impact on any of the growth or body composition findings.

Conclusion

In this long-term study of children participating in a randomized maternal education trial, we found no significant impact of the intervention on anthropometrical z-scores, height growth velocity or body composition.

Trial registration

Clinical Trials (clinical trials.gov) ClinicalTrials.gov ID NCT 02098031.