The interaction of malnutrition and neurologic disability in Africa

Validation study on a prediction formula to estimate the weight of children & adolescents with special needs aged 2-18 years old

BACKGROUND

This study aims to validate two predictive formulas of weight estimating strategies in children with special needs, namely the Cattermole formula and the Mercy formula.

METHODOLOGY

A cross-sectional study with a universal sampling of children and adolescents with special needs aged 2-18 years old, diagnosed with cerebral palsy, down syndrome, autism and attention-deficit/hyperactivity disorder was conducted at Community-Based Rehabilitation in Central Zone Malaysia. Socio-demographic data were obtained from files, and medical reports and anthropometric measurements (body weight, height, humeral length, and mid-upper arm circumference) were collected using standard procedures. Data were analysed using IBM SPSS version 26. The accuracy of the formula was determined by intraclass correlation, prediction at 20% of actual body weight, residual error (RE) and root mean square error (RMSE).

RESULT

A total of 502 children with a median age of 7 (6) years were enrolled in this study. The results showed that the Mercy formula demonstrated a smaller degree of bias than the Cattermole formula (PE = 1.97 ± 15.99% and 21.13 ± 27.76%, respectively). The Mercy formula showed the highest intraclass correlation coefficient (0.936 vs. 0.858) and predicted weight within 20% of the actual value in the largest proportion of participants (84% vs. 48%). The Mercy formula also demonstrated lower RE (0.3 vs. 3.6) and RMSE (3.84 vs. 6.56) compared to the Cattermole formula. Mercy offered the best option for weight estimation in children with special needs in our study population.

Middle-term nitrogen dioxide exposure and electrocardiogram abnormalities: A nationwide longitudinal study

BACKGROUND

Recently, professionals, such as those from the World Health Organization, have recommended a rigorous standard for nitrogen dioxide (NO2), a typical urban air pollutant affected by regular traffic emissions, based on its short-term and long-term cardiorespiratory effects. However, the association between middle-term NO2 exposure and cardiovascular disorders remains unknown.

OBJECTIVES

This study was conducted to examine the relationship between NO2 exposure and its middle-term cardiovascular risks indicated by electrocardiogram (ECG) abnormalities.

METHOD

We included 61,094 subjects (132,249 visits) with repeated ECG observations based on longitudinal data from the China National Stroke Screening Survey (CNSSS). The NO2 exposure concentration was derived from a predictive model, measured as the monthly average concentration in the 6 months of preceding the ECG measurement. We used the generalized estimation equation to assess the association between NO2 exposure and ECG abnormalities.

RESULT

For each 10 µg/m3 increase in monthly average NO2 concentration, the odds ratio of ECG abnormalities was 1.10 (95% confidence interval [CI] 1.09-1.12) after multiple adjustments. Stratified regression analyses of urban and rural residents showed associations between middle-term NO2 exposure and ECG abnormalities in urban (OR 1.09 [95% CI 1.08-1.11]) and rural residents (OR 1.14 [95% CI 1.10-1.19]). The association was robust within different subpopulations. Associations generally remained statistically significant (OR 1.03 [95% CI 1.02-1.05]) after extra adjustment for PM2.5. Exposure-response relationship analysis revealed a nearly linear relationship between NO2 exposure and the risk for ECG abnormalities.

CONCLUSION

Using the variation in ECG signals as a potentially reversible indicator for subclinical risk in cardiovascular systems, our study provides additional evidence on the increased risk posed by middle-term NO2 exposure. Our study showed that policies controlling for NO2 concentrations are beneficial to prevent cardiovascular diseases among Chinese adults.

Global, regional, and national epidemiological trends in neural tube defects between 1990 and 2019: a summary

BACKGROUND

Neural tube defects (NTD), such as spina bifida, are surgically treatable and primarily preventable non-communicable diseases. How incidence, mortality and disability-adjusted life year (DALYs) rates of NTD have modulated over time is not well defined. Correspondingly, the aim of this study was to quantitively define the global, regional, and national epidemiological trends in these.

METHODS

A retrospective review of data from the Global Burden of Disease Study 2019 Database was performed. Global, regional, and national outcomes for NTD were collected for incidence, mortality, and DALY rates and their age-standardized metrics analyzed. There were 7 regions at a regional level, and 204 countries and territories at a national level.

RESULTS

Globally, the latest age-standardized rates of incidence, mortality, and DALYs of NTD were 2.1 per 100,000 population, 1.3 per 1000,000, and 117 per 100,000 respectively. All rates demonstrated decreases in the last two decades to now. Regionally, sub-Saharan Africa and North America demonstrated the highest and lowest age-standardized rates of incidence (4.0 vs 0.5 per 100,000), mortality (3.0 vs 0.4 per 100,000), and DALYs (266 vs 33 per 100,000), respectively. Similar to global trends, all regions demonstrated decrease in these rates over the last two decades. Nationally, the highest age-standardized rates were reported in African countries, Central African Republic, with highest incidence rate (7.6 per 100,000), and Burkina Faso with highest mortality rate (5.8 per 100,000) and DALY rate (518 per 100,000). India was the country with the highest number of new NTD cases (22,000 per country) in the most recent year of study. Between 1990 and 2019, 182/204 (89%), 188/204 (92%), and 188/204 (92%) countries and territories demonstrated a decrease in age-standardized incidence, mortality, and DALY rates respectively, with the greatest decreases seen in Saudi Arabia for all statistics.

CONCLUSIONS

Between 1990 and 2019, overall trends in incidence, mortality, and DALY rates of NTD have been favorably downtrending globally. Regionally, these rates in the highest sub-Saharan Africa were 8 times greater compared to the lowest North America. Nationally, although the majority of countries showed decreases in these rates, a small number of countries demonstrated uptrending rates of NTD. Understanding the mechanics behind these trends will allow future public health endeavors for both prevention and neurosurgical treatment to be targeted appropriately.

Prevalence of children under five with disabilities in Sierra Leone in 2017: Insights from a population-based multiple indicator cluster survey

BACKGROUND

Children with disabilities have been low on the agenda of child health, including in Sierra Leone, and there are still many gaps in our knowledge and understanding of the issue.

OBJECTIVE

To estimate the prevalence of children with disabilities in Sierra Leone using functional difficulty as a proxy and to understand the factors associated with disabilities among children two to four years living in Sierra Leone.

METHODS

We used cross-sectional data from the Sierra Leone 2017 Multiple Indicator Cluster Survey. Disability was defined using a functional difficulty definition with additional thresholds used to define children with severe functional difficulty and multiple disabilities. Logistic regression models estimated odds ratios (ORs) of childhood disability and how they were associated with socioeconomic factors and living conditions.

RESULTS

Prevalence of children with disabilities was 6.6% (95% confidence interval (CI) 5.8-7.6%) and there was a high risk of comorbidity between different functional difficulties. Children with disabilities were less likely to be girls (adjusted odds ratio (AOR) 0.8 (CI 0.7-1.0) and older (AOR 0.3 (CI 0.2-0.4)), but more prone to be stunted (AOR 1.4 (CI 1.1-1.7)) and have younger caregivers (AOR 1.3 (CI 0.7-2.3)).

CONCLUSION

The prevalence of disabilities in young Sierra Leonean children was comparable to other countries in West and Central Africa when using the same measure of disability. Preventive as well as early detection and intervention efforts are recommended to be integrated with other programs, e.g vaccinations, nutrition, and poverty reducing programs.

Nutritional status and growth of children and adolescents with and without cerebral palsy in eastern Uganda: A longitudinal comparative analysis

There is a need to understand the growth and burden of malnutrition in children with cerebral palsy (CP) in order to design appropriate inclusive nutrition strategies. We compared the nutritional status and four-year longitudinal growth of a population-based cohort of children and adolescents (C&A) with CP (n = 97; 2-17 years; 55/42 M/F), and an age and sex matched group without CP (n = 91; 2-17y; 50/41 M/F) in rural Uganda. The cohorts were assessed in 2015 and 2019 for weight, height, social demographic characteristics, and feeding related factors. Nutritional status was determined using the World Health Organization (WHO) Z-scores. Wilcoxon sign rank and Mann-Whitney tests were used to test within and between group differences. Multivariable linear regression was used to determine predictors of the change in growth. Approximately two thirds (62/97 (64%)) of C&A with CP were malnourished (with <-2SD in any of the WHO Z-scores), especially those with feeding difficulties (OR = 2.65; P = 0.032), and those who needed to be fed (OR = 3.8; P = 0.019). Both the CP and non-CP groups deviated negatively from the WHO reference growth curve for height, with a significantly slower growth in the CP group (median change score of height-for-age Z score (HAZ) between assessments = -0.80(-1.56, 0.31), p<0.01), than the non-CP group (median HAZ change score = -0.27(-0.92,0.34, p = 0.034). There was a statistically significant group difference in the median HAZ change score between the CP and non-CP groups (z = -2.21, p = 0.026). Severity of motor impairment measured by the Gross Motor Function Classification System (GMFCS-level) correlated negatively (r = -1.37,95%CI -2.67, -0.08) with the change in HAZ scores among the CP group. Children and adolescents with severe motor impairments exhibit an increased risk of malnutrition and growth retardation compared to their age matched peers without CP, which underscores the need to develop inclusive community-based nutrition strategies for children with cerebral palsy.

Nutritional care for children with feeding difficulties and disabilities: A scoping review

One billion people worldwide have a disability, and 80 percent of them live in low- and middle-income countries (LMICs). The prevalence of feeding difficulties globally ranges from 25-45 percent to 33-80 percent in children without and with disabilities, respectively. The U.S. Agency for International Development's (USAID) flagship multi-sectoral nutrition project, USAID Advancing Nutrition, conducted a scoping review of programs supporting nutritional care of children with disability and non-disability related feeding difficulties. The non-systematic scoping review included a desk review of peer-reviewed and non-peer-reviewed literature and key informant interviews. In all, 127 documents with publication dates ranging from 2003 to 2022 were identified through keyword searches and snowballing and met the inclusion criteria, and 42 experts in nutrition and disability were interviewed. Findings were organized using structured matrices of challenges and opportunities across the universal progressive model of care framework in the identification and management of feeding difficulties and disabilities and support for children with feeding difficulties and disabilities and their families. The review found insufficient policies, programs, and evidence to support children with feeding difficulties and disabilities and their families. While some resources and promising approaches exist, they are not standardized or universally used, staff are not trained to use them, and there is insufficient funding to implement them. The combination of challenges in identifying feeding difficulties and disabilities, a lack of understanding of the link between disabilities and feeding, and weak or nonexistent referral or specialized services puts these children at risk of malnutrition. Additionally, their families face challenges providing the care they need, including coping with high care demands, accessing support, obtaining appropriate foods, and managing stigma. Four areas of recommendations emerged to support children with feeding difficulties and disabilities: (1) Strengthen systems to improve identification and service provision; (2) Provide direct support to families to address determinants that affect nutrition outcomes; (3) Conduct advocacy to raise awareness of the needs and opportunities; and (4) Build the evidence base on effective interventions to identify and support these children and their families.

The significance of MUAC z-scores in diagnosing pediatric malnutrition: A scoping review with special emphasis on neurologically disabled children

This review by a panel of pediatric gastroenterology-hepatology-nutrition and pediatric neurology experts aimed to address the significance of mid-upper arm circumference (MUAC) assessment in diagnosis of pediatric malnutrition. Specifically, the potential utility of recently developed MUAC z-score tape in clinical practice for larger patient populations was addressed including the neurologically disabled children. In accordance with the evidence-based data, four statements were identified by the participating experts on the utility of MUAC z-score tape, including (1) MUAC z-scores correlate with body mass index (BMI) and weight for height/length (WFH/l) z-scores in diagnosing malnutrition; (2) MUAC z-score tape offers a higher sensitivity to diagnose the mild and moderate malnutrition and better ability to track the changes in nutritional status over time than the other single datapoint measurements; (3) Using single-step MUAC z-score tape in children with cerebral palsy (CP) seems to provide more reliable data on anthropometry; and (4) The clinical value of the tool in classifying secondary malnutrition in CP should be investigated in large-scale populations. In conclusion, enabling single-step estimation of nutritional status in a large-scale pediatric population regardless of age and within a wide range of weight, without formal training or the need for ancillary reference charts and calculators, MUAC z-tape offers a favorable tool for easier and earlier diagnosis of pediatric malnutrition. Nonetheless, further implementation of MUAC z-score screening in larger-scale and/or special populations is necessary to justify its utility in relation to other primary anthropometric indicators in diagnosis of malnutrition as well as in treatment monitoring in the community and hospital setting.

Long-Term Exposure to Ozone Increases Neurological Disability after Stroke: Findings from a Nationwide Longitudinal Study in China

Simple Summary

In China, ozone is a major air pollutant that has been linked to stroke incidence and mortality. However, how long-term exposure to ozone affects the life quality among stroke survivors is unknown. This study presents a longitudinal analysis of nationwide data of Chinese adults, and shows that exposure to ozone can increase the risk of post-stroke disability. Taking ambient O₃ under control can delay the progression of neurological disability among stroke survivors.

Abstract

Exposure to ozone (O₃) is associated with stroke incidence and mortality. However, whether long-term exposure to O₃ is associated with post-stroke neurological disability remains unknown. This study investigated the relationship based on the longitudinal analysis of China National Stroke Screening Survey (CNSSS), which included 65,778 records of stroke patients. All of the analyzed patients were followed-up at least twice. Stroke disability was assessed using the modified Rankin scale (mRS). Long-term exposure was assessed by the peak-season or annual mean of maximum 8-h O₃ concentrations for 365 days before the mRS measurement. We used fixed-effect models to evaluate the associations between O₃ and mRS score, with adjustment for multiple confounders, and found a 10 µg/m³ increase in peak-season O₃ concentration was associated with a 0.0186 (95% confidence interval [CI] 0.0115–0.0256) increment in the mRS score. The association was robust in various subpopulations. For secondary outcomes, for each 10 µg/m³ increment in peak-season O₃, the odds ratio of an increased mRS score (vs. unchanged or decreased mRS score) increased by 23% (95% CI 9–37%). A nonlinear analysis showed a sublinear association between O₃ exposure and risk for post-stroke disability. A saturation effect was observed at an O₃ concentration of more than ~120 μg/m³. Our study adds to evidence that long-term exposure to O₃ increases the risk of neurological disability after stroke.

Children living with disabilities are neglected in severe malnutrition protocols: a guideline review

PURPOSE

Children living with disabilities are at high risk of malnutrition but have long been marginalised in malnutrition treatment programmes and research. The 2013 WHO guidelines for severe acute malnutrition (SAM) mention disability but do not contain specific details for treatment or support. This study assesses inclusion of children living with disabilities in national and international SAM guidelines.

METHODS

National and international SAM guidelines available in English, French, Spanish or Portuguese were sourced online and via direct enquiries. Regional guidelines or protocols subspecialising in a certain patient group (eg, people living with HIV) were excluded. Eight scoping key informant interviews were conducted with experts involved in guideline development to help understand possible barriers to formalising malnutrition guidance for children living with disabilities.

RESULTS

71 malnutrition guidelines were reviewed (63 national, 8 international). National guidelines obtained covered the greater part of countries with a high burden of malnutrition. 85% of guidelines (60/71) mention disability, although mostly briefly. Only 4% (3/71) had a specific section for children living with disabilities, while the remaining lacked guidance on consistently including them in programmes or practice. Only one guideline mentioned strategies to include children living with disabilities during a nutritional emergency. Most (99%,70/71) did not link to other disability-specific guidelines. Of the guidelines that included children living with disabilities, most only discussed disability in general terms despite the fact that different interventions are often needed for children with different conditions. Interviews pointed towards barriers related to medical complexity, resource constraints, epidemiology (eg, unrecognised burden), lack of evidence and difficulty of integration into existing guidelines.

CONCLUSION

Children living with disabilities are under-recognised in most SAM guidelines. Where they are recognised, recommendations are very limited. Better evidence is urgently needed to identify and manage children living with disabilities in malnutrition programmes. More inclusion in the 2022 update of the WHO malnutrition guidelines could support this vulnerable group.

Neurological impairment and disability in children in rural Kenya

AIM

To investigate geographical change over time in the burden of neurological impairments in school-aged children in a demographic surveillance area.

METHOD

We investigated changes in neurological impairment prevalence in five domains (epilepsy and cognitive, hearing, vision, and motor impairments) using similar two-phase surveys conducted in 2001 (n=10 218) and 2015 (n=11 223) and determined changes in location-level prevalence, geographical clustering, and significant risk factors for children aged 6 to 9 years (mean 7y 6mo, SD 1y) of whom 50.4% were males. Admission trends for preterm birth, low birthweight (LBW), and encephalopathy were determined using admission data to a local hospital.

RESULTS

Overall prevalence for any neurological impairment decreased from 61 per 1000 (95% confidence interval [CI] 48.0-74.0) in 2001 to 44.7 per 1000 (95% CI 40.9-48.6) in 2015 (p<0.001). There was little evidence of geographical variation in the prevalence of neurological impairments in either survey. The association between neurological impairments and some risk factors changed significantly with year of survey; for example, the increased association of adverse perinatal events with hearing impairments (exponentiated coefficient for the interaction=5.94, p=0.03). Annual admission rates with preterm birth (rate ratio 1.08, range 1.07-1.09), LBW (rate ratio 1.08, range 1.06-1.10), and encephalopathy (rate ratio 1.08, range 1.06-1.09) significantly increased between 2005 and 2016 (p<0.001).

INTERPRETATION

There was a significant decline in the prevalence of neurological impairments and differential changes in the associations of some risk factors with neurological impairments over the study period. Limited geographical variation suggests that similar interventions are appropriate across the defined area.

The burden of neurological impairments and disability in older children measured in disability-adjusted life-years in rural Kenya

Neurological impairment (NI) and disability are common in sub-Saharan Africa (SSA), but the overall burden in terms of morbidity and mortality in older children remains unknown. We estimated the burden of NI in disability-adjusted life years (DALYs), years of life lost to premature mortality (YLLs), and years lived with disability (YLDs) for older children in a defined rural setting in Kenya. We used empirical and literature estimates to model the overall burden for children aged 5-14 years in five domains: epilepsy (lifetime and active) and moderate/severe cognitive, hearing, motor, and visual impairments. We obtained internally consistent estimates of prevalence, mortality, and transitional hazards using DisMod II software. Disability weights and life expectancy estimates were based on the global burden of disease (GBD) studies. We used the most plausible parameters to calculate YLLs, YLDs, and DALYs and their bootstrapped 95% uncertainty intervals (95%UI) for the defined area. NI in the five domains resulted in a total of 4587 (95%UI 4459-4715) absolute DALYs or 53 (95%UI 39-67) DALYs per 1000 children aged 5-14 years, of which 83% were YLLs and 17% YLDs. Girls had significantly more YLLs and DALYs than boys (p-values <0.001, respectively). Besides being the leading cause of fatal and non-fatal outcomes, epilepsy accounted for the greatest proportion of the total burden for a single domain (20 DALYs per 1000, 95%UI 11-26, or 38.5% of the total DALYs). Visual impairment accounted for the least proportion of the total burden (6 per 1000, 95%UI 1-17, or 12.1%). Children with NI and disability bear a significantly high burden of fatal and non-fatal outcomes. The burden is highest among girls and those with childhood-onset epilepsy. We recommend active identification, treatment, and rehabilitative support for the affected children to prevent premature mortality and improve their quality of life.

Cognitive impairment in people with schizophrenia: an umbrella review

Cognitive impairment is one of the core symptoms of schizophrenia. Quite a number of systematic reviews were published related to cognitive impairment in people with schizophrenia (PWS). This umbrella review, therefore, aimed at reviewing and synthesizing the findings of systematic reviews related to domains of cognition impaired and associated factors in PWS. We searched four electronic databases. Data related to domains, occurrence, and associated factors of cognitive impairment in PWS were extracted. The quality of all eligible systematic reviews was assessed using A MeaSurement Tool to Assess methodological quality of systematic Review (AMSTAR) tool. Results are summarized and presented in a narrative form. We identified 63 systematic reviews fulfilling the eligibility criteria. The included reviews showed that PWS had lower cognitive functioning compared to both healthy controls and people with affective disorders. Similar findings were reported among psychotropic free cases and people with first episode psychosis. Greater impairment of cognition was reported in processing speed, verbal memory, and working memory domains. Greater cognitive impairment was reported to be associated with worse functionality and poor insight. Cognitive impairment was also reported to be associated with childhood trauma and aggressive behaviour. According to our quality assessment, the majority of the reviews had moderate quality. We were able to find a good number of systematic reviews on cognitive impairment in PWS. The reviews showed that PWS had higher impairment in different cognitive domains compared to healthy controls and people with affective disorders. Impairment in domains of memory and processing speed were reported frequently.

"I'm scared to talk about it": exploring experiences of incontinence for people with and without disabilities in Vanuatu, using mixed methods

Background

Incontinence is the involuntary loss of urine and/or faeces. It is stigmatised and can reduce quality of life. People with incontinence require water, sanitation, hygiene (WASH) and incontinence products. People with disabilities are at risk of experiencing incontinence and may face challenges managing, however, minimal evidence exists.

Methods

This study aimed to complete a population-based study of disability in TORBA and SANMA Provinces, Vanuatu to quantify the prevalence and demographics of disability, experience of WASH access and incontinence for people with and without disabilities. We completed a survey, case-control study, in-depth interviews, structured observations and PhotoVoice. 179 people with disabilities and 148 people without disabilities completed the incontinence module in the case-control study. We applied purposeful sampling to select 27 people with and without a disability from the nested case-control, and 16 key informants for the qualitative study to further explore the impact of incontinence on people's lives.

Findings

People with disabilities were three times more likely to experience incontinence than people without disabilities (Adjusted Odds Ratio 3.3, 95% confidence interval 1.8 – 5.8). Challenges facing all people with incontinence were distance to latrines and lack of incontinence products. People with disabilities were less able to wash and participate in social activities. Less than 10% had assistive technologies; caregivers had no lifting devices. People experiencing incontinence did not disclose this to others, including medical professionals, who also did not raise the issue.

Interpretation

Inaccessible and inadequate WASH, lack of incontinence products and stigma increased isolation for all people with incontinence. Additionally, people with disabilities and caregivers faced discrimination and insufficient assistive technologies. This negatively affected their wellbeing and quality of life, and requires addressing.

Funding

Australian Government's Water for Women Fund and public donations.

Assessment of Swallowing Disorders, Nutritional and Hydration Status, and Oral Hygiene in Students with Severe Neurological Disabilities Including Cerebral Palsy

BACKGROUND

Special needs schools (SNS) educate children and young people with major neurological disabilities who are at high risk of oropharyngeal dysphagia (OD) and malnutrition (MN). We aimed to assess the prevalence of OD, MN, dehydration (DH), and oral health (OH) in students at an SNS.

METHODS

A cross-sectional observational study was conducted at SNS L'Arboç, Catalonia, Spain. We assessed (a) demographics, health status, comorbidities, and gross motor function classification system (GMFCS), (b) swallowing function, oral-motor evaluation, masticatory capacity, and EDACS classification for eating and drinking abilities, (c) nutritional and DH status (anthropometry, bioimpedance and dietary records), and (d) OH (Oral Hygiene Index Simplified).

RESULTS

A total of 33 students (mean age 13.3 years; 39.4% level V of GMFCS) were included. Main diagnosis was cerebral palsy at 57.6%. All students presented OD, 90.6% had impaired safety, 68.7% were at levels II-III of EDACS, and 31.3% required PEG; furthermore, 89.3% had chronic MN, 21.4% had acute MN, 70% presented intracellular DH, and 83.9% presented impaired OH.

CONCLUSION

MN, DH, OD, and poor OH are highly prevalent conditions in students with cerebral palsy and other neurological disabilities and must be specifically managed through nutritional and educational strategies. The multidisciplinary team at SNS should include healthcare professionals specifically trained in these conditions.

Nutritional Disorders in a Group of Children and Adolescents with Syndromes or Diseases Involving Neurodysfunction

A study of the literature shows the lack of data on a comprehensive analysis of eating disorders in children with neurodysfunction, which constitute a clinical subgroup with an increased risk of abnormalities in this area. Therefore, the aim of this study was to determine the relationship between the coexistence of nutritional disorders and diseases or syndromes associated with neurodysfunction based on data collected during hospitalization at a rehabilitation center for children and adolescents. A retrospective analysis was carried out in a group of 327 children and adolescents aged 4–18 years. The study group covered various types of diseases or syndromes involving damage to the central nervous system. A retrospective analysis of baseline data (age, sex, main and additional diagnosis and Body Mass Index—BMI) was performed. Two assessment criteria of nutritional status were taken into account (z-score BMI and other previously published normative values). In the study group, malnutrition was found more frequently (18.0% of the respondents) than obesity (11.3% of the subjects). Hypothyroidism coexisting with malnutrition was identified in the study group (N% = 43.8%, p = 0.011) and malnutrition with tetraplegia in the subgroup of spastic cerebral palsy (N% = 34.2 %, p = 0.029).

Evaluation of an mHealth tool to improve nutritional assessment among infants under 6 months in paediatric development clinics in rural Rwanda: Quasi-experimental study

Infants born preterm, low birthweight or with other perinatal complications require frequent and accurate growth monitoring for optimal nutrition and growth. We implemented an mHealth tool to improve growth monitoring and nutritional status assessment of high risk infants. We conducted a pre-post quasi-experimental study with a concurrent control group among infants enrolled in paediatric development clinics in two rural Rwandan districts. During the pre-intervention period (August 2017-January 2018), all clinics used standard paper-based World Health Organization (WHO) growth charts. During the intervention period (August 2018-January 2019), Kirehe district adopted an mHealth tool for child growth monitoring and nutritional status assessment. Data on length/height; weight; length/height-for-age (L/HFA), weight-for-length/height (WFL/H) and weight-for-age (WFA) z-scores; and interval growth were tracked at each visit. We conducted a 'difference-in-difference' analysis to assess whether the mHealth tool was associated with greater improvements in completion and accuracy of nutritional assessments and nutritional status at 2 and 6 months of age. We observed 3529 visits. mHealth intervention clinics showed significantly greater improvements on completeness for corrected age (endline: 65% vs. 55%; p = 0.036), L/HFA (endline: 82% vs. 57%; p ≤ 0.001), WFA (endline: 93% vs. 67%; p ≤ 0.001) and WFL/H (endline: 90% vs. 59%; p ≤ 0.001) z-scores compared with control sites. Accuracy of growth monitoring did not improve. Prevalence of stunting, underweight and inadequate interval growth at 6-months corrected age decreased significantly more in the intervention clinics than in control clinics. Results suggest that integrating mHealth nutrition interventions is feasible and can improve child nutrition outcomes. Improved tool design may better promote accuracy.

Socio-demographic factors and health status of adults with disability in Enugu Metropolis, Nigeria

Background

Disability is a major determinant of impaired health and nutritional status. This study aims to assess the health and nutritional status of adults with disability and their relationship with socio-demographic factors.

Methods

A descriptive cross-sectional study of 323 adults with disability in support-centers/schools of disability in Enugu Metropolis, Nigeria was conducted. The participants' socio-demographic factors, behavioural characteristics and 24-hour dietary recall were recorded. Blood pressure and anthropometric measurements of height, weight, waist and hip circumference were obtained. The height and weight measurements of non-ambulatory participants were estimated from knee height and mid-arm circumference. Biochemical analyses of blood samples were also performed. Multiple logistic regression was used to assess the effect of socio-demographic factors on health and nutritional status.

Results

The participants consisted of females (59.3%) within the age of 20 to 30 years (59.1%). The major area of difficulty was in physical mobility (51.1%) and this occurred mostly in females (26.9%). The participants' mean daily intakes of calorie, protein and fat were below the recommended dietary allowances. The participants were overweight (49.2%), obese (4.6%), hypertensive (29.7%) and diabetic (12.1%). Dyslipidemia (81.8%), anemia (63.6%) and zinc deficiency (51.1%) were highly prevalent among the study group. Gender difference was observed in alcohol consumption (p=0.000), smoking habit (p=0.001), waist circumference (WC)(p=0.000), waist-hip-ratio (WHR) (p=0.000), triglyceride (p=0.026) and haemoglobin concentration (p=0.007). Being boarder was a positive predictor of overweight/obesity (OR= 2.974, 95% CI=1.449-6.104), abnormal WHR (OR=2.893, 95% CI = 1.073-7.801) and hypertension (OR=8.381, 95% CI=1.598-13.959). Female gender was associated with abnormal WC (OR=7.219, 95% CI=3.116-14.228) and WHR (OR=3.590, 95% CI=2.095-6.150) whereas older age-group was associated with overweight/obesity (OR=1.908, 95% CI=1.137- 3.202). Being employed was a negative predictor of hypertension.

Conclusion

Overweight/obesity, anemia, zinc deficiency and dyslipidemia were highly prevalent among persons living with disability in Enugu Metropolis.

A Review of the Scope of Artisanal and Small-Scale Mining Worldwide, Poverty, and the Associated Health Impacts

Some of the poorest people in the world's poorest countries eke out a living in artisanal and small-scale mining (ASM). Equipped with primitive tools like picks, shovels, buckets, and gold pans, they work mining valuable resources, like gold, diamonds, tin, lithium, rare earth elements, tantalum, and cobalt, and any other usable commodity, for example, sand, coal, or mica. The mining and refining processes are labor intensive and associated with a variety of health problems due to accidents, overheating, overexertion, dust inhalation, exposure to toxic chemicals and gases, violence, and illicit and prescription drug and alcohol addiction. Evident disadvantages with ASM are counterbalanced by the immense economic benefits. For many, the true scope and scale of ASM activities are unappreciated, along with the unknown health and societal impacts. Here, we set out to elucidate the scope of ASM beyond the recovery of familiar commodities, such as gold and diamonds. We adopt a holistic perspective toward health impacts of ASM, which includes unique occupational, environmental, and human/social drivers. A particular focus is poverty as a health risk with artisanal miners. They are commonly poverty-stricken people in poor countries, ensnared by a variety of poverty traps, which take a toll on the health and well-being of individuals and communities. ASM sometimes provides an opportunity to diversify income in the face of a decline in subsistence agriculture. However, ASM often trades one kind of generational poverty for another, coming along with serious health risks and turmoil associated with work in an informal "cash-rich" business.

Long-term outcomes for children with disability and severe acute malnutrition in Malawi

Introduction

Severe acute malnutrition (SAM) and disability are major global health issues. Although they can cause and influence each other, data on their co-existence are sparse. We aimed to describe the prevalence and patterns of disability among a cohort of children with SAM.

Methods

A longitudinal cohort study in Malawi followed SAM survivors up to 7 years postdischarge. Clinical and anthropometric profiles were compared with sibling and community controls. Disability at original admission was identified clinically; at 7-year follow-up a standardised screening tool called ‘the Washington Group Questionnaire’ was used.

Results

60/938 (6.4%) of admissions to SAM treatment had clinically obvious disability at admission. Post-treatment mortality was high, with only 11/60 (18%) surviving till 7-year follow-up. SAM children with a disability at admission had 6.99 (95% CI 3.49 to 14.02; p<0.001) greater risk of dying compared with children without disability. They were also older, less likely to be HIV positive or have oedema and more severely malnourished. Long-term survivors were more stunted, had less catch-up growth, smaller head circumference, weaker hand grip strength and poorer school achievement than non-disabled survivors.

The Washington Group Questionnaire confirmed disability in all who had been identified clinically, and identified many who had not been previously flagged.

Conclusion

Disability is common among children affected by SAM. Those with disability-associated SAM have greatly increased risk of dying even if they survive the initial episode of malnutrition. Survivors have poorer growth, physical strength and school achievement. To enable all children to survive and thrive post-SAM, it is vital to focus more on those with disabilities. SAM treatment programmes should consider using not just clinical assessment but structured assessments to better identify at-risk individuals as well as understand the population of children for which they are developing services.

High Burden of Undernutrition among At-Risk Children in Neonatal Follow-Up Clinic in Rwanda

Background

Sufficient knowledge of the disproportionate burden of undernutrition among vulnerable children is required for accelerating undernutrition reduction in low-income countries.

Objectives

We aimed to assess the prevalence of stunting, underweight and wasting and associated factors among high-risk children born preterm, with low birth weight or other birth and neurodevelopmental injuries, who received nutritional support and clinical care follow-up in a Pediatric Development Clinic (PDC) in rural Rwanda.

Methods

This cross-sectional study included all children from rural areas enrolled in PDC between April 2014-September 2017 aged 6-59 months at their last visit during this period. Anthropometric measurements, socioeconomic and clinical characteristics were extracted from an electronic medical records system. We used the World Health Organization child growth standards to classify stunting, underweight and wasting. Factors associated with undernutrition were identified using logistic regression analysis.

Results

Of 641 children, 58.8% were stunted, 47.5% were underweight and 25.8% were wasted. Small for gestational age was associated with increased odds of stunting [OR 2.63; 95% CI 1.58-4.36] and underweight (OR 2.33; 95% CI 1.46-3.71), while history of feeding difficulties was significantly associated with wasting (OR: 3.36; 95% CI: 2.20-5.13) and underweight (OR: 2.68; 95% CI: 1.78-4.04). Later age at PDC enrollment was associated with increased odds of stunting (OR: 1.06; 95% CI: 1.01-1.11), underweight (OR: 1.09; 95% CI: 1.05-1.14) and wasting (OR: 1.07; 95% CI: 1.04-1.10).

Conclusions

The prevalence of stunting, underweight and wasting are high in this at-risk population, highlighting the need for specific interventions to address undernutrition among children with similar characteristics. Early PDC enrollment of high-risk infants may reduce undernutrition risk.

Nutritional Influences on the Health of Women and Children in Cabo Delgado, Mozambique: A Qualitative Study

In 2017, the Government of Mozambique declared localized acute malnutrition crises in a range of districts across Mozambique including Cabo Delgado. This is in spite of intensive efforts by different non-governmental organizations (NGO) and the Government of Mozambique to expand access to information on good nutritional practices as well as promote nutrition-specific interventions, such as cooking demonstrations, home gardens and the distribution of micronutrient powder to children. This paper examines and discusses key nutritional influences on the health of pregnant and breastfeeding mothers in Cabo Delgado province, Mozambique. We conducted 21 key informant interviews (KIIs) with a wide range of stakeholders and 16 in-depth interviews (IDIs) with women. In addition, we conducted four focus group discussions with each of the following groups: (1) pregnant adolescent girls, (2) pregnant women >20 yrs, (3) women >20 yrs with babies <6 mths who were not practicing exclusive breastfeeding, (4) women >20 yrs of children <2 yrs and (5) with fathers of children <2 yrs. Data were analyzed thematically using NVIVO software. There is no single widely held influence on pregnant and breast-feeding women’s nutritional decision-making, choices and food consumption. Rather, variables such as social-cultural, environmental, economic, gender, knowledge and information intersect in their roles in nutritional food choices.

Nutritional evaluation and growth of infants in a Rwandan neonatal follow-up clinic

Children born preterm, low birth weight (LBW) or with other perinatal risk factors are at high‐risk of malnutrition. Regular growth monitoring and early intervention are essential to promote optimal feeding and growth; however, monitoring growth in preterm infants can be complex. This study evaluated growth monitoring of infants under 6 months enrolled in Paediatric Development Clinics (PDCs) in rural Rwanda. We reviewed electronic medical records (EMR) of infants enrolled in PDCs before age 2 months with their first visit between January 2015 and December 2016 and followed them until age 6 months. Nurse classification of anthropometric measures and nutritional status were extracted from the EMR. Interval growth and length‐for‐age, weight‐for‐length, and weight‐for‐age z‐scores were calculated using World Health Organization anthropometry software as a ‘gold standard’ comparison to nurse classifications. Two hundred and ninety‐four patients enrolled and had 2,033 visits during the study period. Referral reasons included prematurity/LBW (73.8%) and hypoxic ischemic encephalopathy (28.2%). Nurses assessed interval growth at 58.7% of visits, length‐for‐age at 66.4%, weight‐for‐length at 65.6% and weight‐for‐age at 66.4%. Nurses and gold standard assessment agreed on interval growth at 53.3% of visits and length‐for‐age at 63.7%, weight‐for‐length at 78.2% and weight‐for‐age at 66.3%. At 6 months, 46.5% were stunted, 19.9% were wasted and 44.2% were underweight. There were significant challenges to optimizing growth and growth monitoring among high‐risk infants served by PDCs, including incomplete and inaccurate assessments. Developing tools for clinician decision support in assessing growth and providing specialized nutritional counselling are essential to supporting optimal outcomes in this population.

Improving nutritional status of children with Cerebral palsy: a qualitative study of caregiver experiences and community-based training in Ghana

BACKGROUND

Cerebral palsy (CP) is the most common childhood disability worldwide, and evidence shows that children with CP are at an increased risk of malnutrition due to feeding difficulties. This qualitative study explores caregiver experiences of feeding before and after a community-based training program in Ghana.

METHODS

Thirteen caregivers of children with CP, who were severely undernourished, were interviewed at the start of the training program. Eleven of these were interviewed again after a year of monthly group trainings and home visits, which included guidance on feeding. Four additional caregivers were interviewed at end line. Interviews explored caregivers' mealtime experiences, as well as a 24-hr dietary recall and a structured feeding observation checklist. Children's nutritional status was assessed by anthropometry.

RESULTS

Caregivers found mealtimes stressful due to time demands, messiness, and the pressure of providing enough quality food. They felt that the training program had helped reduced this stress and dietary recall data suggested some improved dietary quality. However, there was neither improvement nor deterioration in anthropometric status of the children.

CONCLUSION

Group trainings were welcomed by caregivers and notably reduced stress around feeding times. However, future work is needed in order to improve anthropometric outcomes, including, but not limited to, greater focus on nutritional requirements during caregiver training interventions. Therapeutic feeding programs must also be better utilized and need to be better equipped to care for this group of children, including deviating from standard admission and treatment protocols.

Neural Deletion of Glucose Transporter Isoform 3 Creates Distinct Postnatal and Adult Neurobehavioral Phenotypes

We created a neural-specific conditional murine glut3 (Slc2A3) deletion (glut3 ^{flox/flox/nestin-Cre+}) to examine the effect of a lack of Glut3 on neurodevelopment. Compared with age-matched glut3 ^flox/flox = WT and heterozygotes (glut3 ^{flox/+/nestin-Cre+}), we found that a >90% reduction in male and female brain Glut3 occurred by postnatal day 15 (PN15) in glut3 ^{flox/flox/nestin-Cre+} This genetic manipulation caused a diminution in brain weight and cortical thickness at PN15, a reduced number of dendritic spines, and fewer ultrasonic vocalizations. Patch-clamp recordings of cortical pyramidal neurons revealed increased frequency of bicuculline-induced paroxysmal discharges as well as reduced latency, attesting to a functional synaptic and cortical hyperexcitability. Concomitant stunting with lower glucose concentrations despite increased milk intake shortened the lifespan, failing rescue by a ketogenic diet. This led to creating glut3 ^{flox/flox/CaMK2α-Cre+} mice lacking Glut3 in the adult male limbic system. These mice had normal lifespan, displayed reduced IPSCs in cortical pyramidal neurons, less anxiety/fear, and lowered spatial memory and motor abilities but heightened exploratory and social responses. These distinct postnatal and adult phenotypes, based upon whether glut3 gene is globally or restrictively absent, have implications for humans who carry copy number variations and present with neurodevelopmental disorders.SIGNIFICANCE STATEMENT Lack of the key brain-specific glucose transporter 3 gene found in neurons during early postnatal life results in significant stunting, a reduction in dendritic spines found on neuronal processes and brain size, heightened neuronal excitability, along with a shortened lifespan. When occurring in the adult and limited to the limbic system alone, lack of this gene in neurons reduces the fear of spatial exploration and socialization but does not affect the lifespan. These features are distinct heralding differences between postnatal and adult phenotypes based upon whether the same gene is globally or restrictively lacking. These findings have implications for humans who carry copy number variations pertinent to this gene and have been described to present with neurodevelopmental disorders.

The association between malnutrition and childhood disability in low- and middle- income countries: systematic review and meta-analysis of observational studies

OBJECTIVE

The aim of this study was to evaluate the association between childhood disability and malnutrition in low- and middle- income countries (LMICs).

METHODS

Articles were identified from 1990 to August 2017 by searching nine electronic databases. Epidemiological studies, undertaken in LMICs that compared the prevalence of malnutrition in children with disabilities to children without disabilities were eligible for inclusion. Titles, abstracts, and full texts were screened by two reviewers, and data were extracted using a structured table for eligible papers. Meta-analyses for the association between childhood disability and undernutrition were performed.

RESULTS

The search generated 4678 results, from which 17 articles were eligible. Fifty-three per cent of these studies showed a positive association between childhood disability and undernutrition. Results varied when disaggregated by type of disability, with positive associations identified for 44% of studies focussed on neurodevelopmental disability, 60% of general disability studies and 67% of studies on hearing impairment. Only four studies were identified that considered overnutrition outcomes, and these showed variable results. Eighteen per cent of eligible studies were considered at low risk of bias, 53% had a medium risk, and 29% had a high risk of bias. Pooled ORs showed that children with disabilities were almost three times more likely to be underweight (OR 2.97, 95% CI 2.33, 3.79), and nearly twice as likely to experience stunting and wasting (Stunting: 1.82, 1.40, 2.36; Wasting: 1.90, 1.32-2.75), compared to controls.

CONCLUSIONS

Children with disabilities may be a vulnerable group for undernutrition in LMICs, which should be reflected in disability and nutritional programming and policy-making.

Children with cerebral palsy in Ghana: malnutrition, feeding challenges, and caregiver quality of life

AIM

To assess feeding difficulties and nutritional status among children with cerebral palsy (CP) in Ghana, and whether severity of feeding difficulties and malnutrition are independently associated with caregiver quality of life (QoL).

METHOD

This cross-sectional survey included 76 children with CP (18mo-12y) from four regions of Ghana. Severity of CP was classified using the Gross Motor Function Classification System and anthropometric measures were taken. Caregivers rated their QoL (using the Pediatric Quality of Life Inventory Family Impact Module) and difficulties with eight aspects of child feeding. Logistic regression analysis explored factors (socio-economic characteristics, severity of CP, and feeding difficulties) associated with being underweight. Linear regression was undertaken to assess the relationship between caregiver QoL and child malnutrition and feeding difficulties.

RESULTS

Poor nutritional status was common: 65% of children aged under 5 years were categorized as underweight, 54% as stunted, and 58% as wasted. Reported difficulties with child's feeding were common and were associated with the child being underweight (odds ratio 10.7, 95% confidence interval 2.3-49.6) and poorer caregiver QoL (p<0.001). No association between caregiver QoL and nutritional status was evident.

INTERPRETATION

Among rural, low resource populations in Ghana, there is a need for appropriate, accessible caregiver training and support around feeding practices of children with CP, to improve child nutritional status and caregiver well-being.

WHAT THIS PAPER ADDS

Malnutrition is very common among children with cerebral palsy in this rural population in Ghana. Feeding difficulties in this population were strongly associated with being underweight. Feeding difficulties were associated with poorer caregiver quality of life (QoL). Child nutritional status was not associated with caregiver QoL.

Severe functional difficulties and disabilities in children and adolescents and the Sustainable Development Goals

OBJECTIVE

To report prevalence of severe child functional difficulties and disability (CFD) in a nationally representative sample of 2 to 17 year-old children in Mexico and describe the inequities faced by children with CFD in relation to a set of Sustainable Development Goals (SDG)-related outcomes.

MATERIALS AND METHODS

Using data from the National Survey of Children and Women (ENIM 2015) we estimate prevalence with 95% confidence intervals for the selected indicators. We use chi-square test and confidence intervals inspection to report significant differences between children with and without CFD.

RESULTS

8% of children present at least one CFD. CFD is associated with higher prevalence of underweight and child labor and lower prevalence of adequate early child development. Conclusion. Children with CFD present worst outcomes and require targeted efforts to ensure they meet health and wellbeing targets in the frame of the SDGs.

Balanced diets in food systems: Emerging trends and challenges for human health

Processed foods, generally known as modified raw foods produced by innovative processing technologies alters the food constituents such natural enzymes, fatty acids, micronutrients, macronutrients and vitamins. In contrast to fresh and unprocessed foods, processed foods are guaranteed to be safer, imperishable, long lasting and consist high level of nutrients bioactivity. Currently, the evolution in food processing technologies is necessary to face food security and safety, nutrition demand, its availability and also other global challenges in the food system. In this scenario, this review consists of information on two food processing technologies, which effects on processed foods before and after processing and the impact of food products on human health. It is also very well established that understanding the type and structure of foods to be processed can assist food processing industries towards advancement of novel food products. In connection with this fact, the present article also discusses the emerging trends and possible modifications in food processing technologies with the combination of conventional and modern techniques to get the suitable nutritional and safety qualities in food.

The intersection of disability and food security: Perspectives of health and humanitarian aid workers

Background

Most people with disabilities the world over can be found in the Majority (or 'economically developing') World. This is also where most of the world's hungry and malnourished are found. We argue that the intersectionality between disability and nutrition may best be understood through a food security framework, and we position all people living with disability, including those experiencing feeding and swallowing disabilities, as at risk for food insecurity, especially those living in humanitarian emergency contexts.

Objectives

This study aimed to explore and describe the knowledge and experience of humanitarian aid workers (HAWs) and health care professionals (HCPs) in food assistance contexts with regard to the nutrition and food security of people living with disabilities.

Method

In this exploratory, descriptive study, 16 participants with experience in sub-Saharan Africa and Southern Asia participated in an online survey. Three survey participants with extensive experience were also interviewed. Data analysis involved descriptive statistics and thematic content analysis.

Results

Results revealed that participants had generally low levels of exposure to and experience with disability, including swallowing and feeding disorders.

Conclusions

Reduced knowledge of HAWs and HCPs regarding disability and the lack of professionals such as speech-language therapists, who manage disability-specific issues such as feeding and swallowing disorders, may affect the food security of people living with disabilities in food assistance contexts.

Developmental and behavioural problems in children with severe acute malnutrition in Malawi: A cross-sectional study

Background

Early childhood development provides an important foundation for the development of human capital. Although there is a clear relation between stunting and child development outcomes, less information is available about the developmental and behavioural outcomes of children with severe acute malnutrition (SAM). Particularly an important research gap exists in Sub–Saharan Africa where there is a high prevalence of SAM and a high rate of co–occurring HIV (human immune deficiency virus) infection. Our first objective was to assess the prevalence and severity of developmental and behavioural disorders on a cohort of children admitted to an inpatient nutritional rehabilitation centre in Malawi. Our second objective was to compare the developmental and behavioural profiles of children with the two main phenotypes of SAM: kwashiorkor and marasmus.

Methods

This was a cross–sectional observational study including all children hospitalized with complicated SAM in Blantyre, Malawi over an 8–month period from February to October 2015. At discharge, children were assessed with the well-validated Malawi Developmental Assessment Tool (MDAT) for gross motor, fine motor, language and social development. In children ≥24 months, emotional and behavioural problems were measured using the Strengths and Difficulties Questionnaire (SDQ).

Results

150 children (55% boys) with SAM were recruited; mean age of 27.2 months (standard deviation 17.9), 27 children (18%) had pre–existing neurodisabilities (ND) and 34 (23%) had a co–occurring human immune deficiency virus (HIV) infection. All children with SAM experienced profound delays in the gross and fine motor, language and social domains. Linear regression analysis demonstrated that children with kwashiorkor scored 0.75 standard deviations lower (95% confidence interval –1.43 to –0.07) on language MDAT domain than children with marasmus when adjusted for covariates. The prosocial behaviour score of the SDQ was low in children with SAM, indicating a lack of sensitive behaviour in social interactions.

Conclusions

Children with SAM have severe developmental delays after a hospital admission. Our results indicate that there might be a significant difference in developmental attainment between children with kwashiorkor and with marasmus. Future studies exploring longer–term outcomes and testing possible intervention strategies are urgently needed.

UV Radiation Associates With State Income Through Complex Cognitive Ability in the USA

Abstract. Economic development and national intelligence decline with proximity to the equator. Absolute latitude associates with both, income and IQ, but the nature of their relationship is ambiguous. This study applied structural equation modeling using secondary data pertaining to the 48 contiguous states of the United States of America to test the hypothesis that UV (ultraviolet) radiation associates with income through complex cognitive ability vis-a-vis the hypothesis that UV radiation associates with complex cognitive ability through income. The resulting evidence was consistent with the ability → income pathway and unsupportive of the income → ability model. The findings uphold the cognitive capitalism perspective and may throw light on the evolvement of regional differences in the USA.

Severe childhood malnutrition

The main forms of childhood malnutrition occur predominantly in children <5 years of age living in low-income and middle-income countries and include stunting, wasting and kwashiorkor, of which severe wasting and kwashiorkor are commonly referred to as severe acute malnutrition. Here, we use the term 'severe malnutrition' to describe these conditions to better reflect the contributions of chronic poverty, poor living conditions with pervasive deficits in sanitation and hygiene, a high prevalence of infectious diseases and environmental insults, food insecurity, poor maternal and fetal nutritional status and suboptimal nutritional intake in infancy and early childhood. Children with severe malnutrition have an increased risk of serious illness and death, primarily from acute infectious diseases. International growth standards are used for the diagnosis of severe malnutrition and provide therapeutic end points. The early detection of severe wasting and kwashiorkor and outpatient therapy for these conditions using ready-to-use therapeutic foods form the cornerstone of modern therapy, and only a small percentage of children require inpatient care. However, the normalization of physiological and metabolic functions in children with malnutrition is challenging, and children remain at high risk of relapse and death. Further research is urgently needed to improve our understanding of the pathophysiology of severe malnutrition, especially the mechanisms causing kwashiorkor, and to develop new interventions for prevention and treatment.

Ethnopharmacological values of cassava and its potential for diabetes and dyslipidemia management: Knowledge survey and critical review of report

Background:

Beyond nutritional values are the pharmacological potentials of cassava comparative with other staple carbohydrate plant-based foods such as wheat. The knowledge of applicability to diabetes and its cardiovascular complications management seems not just limited but unacknowledged. As a preliminary study, a community’s knowledge of pharmacological value of cassava is investigated.

Methods:

Descriptive observational study using questionnaire-based “cross-sectional” survey was conducted. 136 Participants completed the survey and 101 respondents were selected for evaluation. Open-ended questions were used qualitatively to generate experience and view cassava values for diabetes and dyslipidemia. While categorical (yes or no) questions were used quantitatively to generate numerical results for diabetes, critical reanalysis of a report data was performed, especially comparing carbohydrate/fiber and fat/fiber ratios of cassava with wheat in view of dyslipidemia.

Result:

On the positive side, 42% of the participants believe that cassava has medicinal values. This includes 6% (among the 42) who believes that the plant is useful in treating diabetes and 24% who do not know it may be useful in diabetes management. Critical review showed that cassava may contribute up to sixteen times more fiber and four times less digestible sugar, as well as carbohydrate/fiber and fat/fiber ratios being 14 and 55 times less than wheat.

Conclusion:

There is evidence that relative to wheat flour meal, for instance, cassava contributes less fat and much more fiber. Since fat is pro-obesity, which in turn is pro-diabetic/metabolic syndrome; and fiber is anti-dyslipidemic; cassava has pharmacological values to be appreciated over some carbohydrate plant-based foods.

UV Radiation Is Associated With Latitudinal Trends in Cognitive Ability of White Children in the USA

Abstract. Temperature, geo-residential pattern of subpopulations, prevalence of infectious diseases, and UV radiation have been proposed to explain the declining cognitive ability observed with proximity to the equator in the USA. This study tested the cognitive effects of the four variables. The results reveal that the latitudinal decline of cognitive ability is strongly correlated with the UV Index rather than with the other variables among White children. The decline in measured cognitive ability from north to south is absent among African American and Hispanic children, plausibly because the high levels of skin melanin among these ethnic groups, by absorbing and dissipating light, prevent the occurrence of radiation’s cognitive effects among these populations at USA latitudes. The possible physiological mediators (oxidative stress, folate degradation, sexual hormones) suggest diet, family planning, and educational methods as mitigating strategies; however, specific studies measuring the mediating variables are needed to confirm their role and further strengthen UV radiation as an explanatory concept.

Risk Factors for Malnutrition Among Children With Cerebral Palsy in Botswana

BACKGROUND

Children with cerebral palsy in low-resource settings are at high risk of malnutrition, which further increases their risk of poor health outcomes. However, there are few available data on specific risk factors for malnutrition among children with cerebral palsy in the developing world.

METHODS

We performed a case-control study among children with cerebral palsy receiving care at a tertiary care hospital in Gaborone, Botswana. Children with cerebral palsy and malnutrition were identified according to World Health Organization growth curves and compared with subjects with cerebral palsy without malnutrition. Risk factors for malnutrition were identified using multivariable logistic regression models. These risk factors were then used to generate a Malnutrition Risk Score, and Receiver Operating Characteristic curves were used to identify optimal cutoffs to identify subjects at high risk of malnutrition.

RESULTS

We identified 61 children with cerebral palsy, 26 of whom (43%) met criteria for malnutrition. Nonambulatory status (odds ratio 13.8, 95% confidence interval [CI] 3.8-50.1, P < 0.001) and a composite measure of socioeconomic status (odds ratio 1.6, 95% CI 1.0-2.5, P = 0.03) were the strongest risk factors for malnutrition. A Malnutrition Risk Score was constructed based on these risk factors, and receiver operating characteristic curve analysis demonstrated excellent performance characteristics of this score (area under the curve 0.92, 95% CI 0.89-0.94).

CONCLUSIONS

Malnutrition is common among children with cerebral palsy in Botswana, and a simple risk score may help identify children with the highest risk. Further studies are needed to validate this screening tool and to determine optimal nutritional interventions in this population.

Metabolomic Changes in Serum of Children with Different Clinical Diagnoses of Malnutrition

Background: Mortality in children with severe acute malnutrition (SAM) remains high despite standardized rehabilitation protocols. Two forms of SAM are classically distinguished: kwashiorkor and marasmus. Children with kwashiorkor have nutritional edema and metabolic disturbances, including hypoalbuminemia and hepatic steatosis, whereas marasmus is characterized by severe wasting. The metabolic changes underlying these phenotypes have been poorly characterized, and whether homeostasis is achieved during hospital stay is unclear.

Objectives: We aimed to characterize metabolic differences between children with marasmus and kwashiorkor at hospital admission and after clinical stabilization and to compare them with stunted and nonstunted community controls.

Methods: We studied children aged 9–59 mo from Malawi who were hospitalized with SAM (n = 40; 21 with kwashiorkor and 19 with marasmus) or living in the community (n = 157; 78 stunted and 79 nonstunted). Serum from patients with SAM was obtained at hospital admission and 3 d after nutritional stabilization and from community controls. With the use of targeted metabolomics, 141 metabolites, including amino acids, biogenic amines, acylcarnitines, sphingomyelins, and phosphatidylcholines, were measured.

Results: At admission, most metabolites (128 of 141; 91%) were lower in children with kwashiorkor than in those with marasmus, with significant differences in several amino acids and biogenic amines, including those of the kynurenine-tryptophan pathway. Several phosphatidylcholines and some acylcarnitines also differed. Patients with SAM had profiles that were profoundly different from those of stunted and nonstunted controls, even after clinical stabilization. Amino acids and biogenic amines generally improved with nutritional rehabilitation, but most sphingomyelins and phosphatidylcholines did not.

Conclusions: Children with kwashiorkor were metabolically distinct from those with marasmus, and were more prone to severe metabolic disruptions. Children with SAM showed metabolic profiles that were profoundly different from stunted and nonstunted controls, even after clinical stabilization. Therefore, metabolic recovery in children with SAM likely extends beyond discharge, which may explain the poor long-term outcomes in these children. This trial was registered at isrctn.org as ISRCTN13916953.

Telomerase activity in pregnancy complications (Review)

Telomeres are specific DNA regions positioned at the ends of chromosomes and composed of functional non-coding repeats. Upon cell division, the telomeres decrease in length by a preordained amount. When the telomeres become critically short, cells lose the ability to divide and enter a specific functioning mode designated as 'cellular senescence'. However, human tissues express an enzyme that deters the shrinking of the telomeres, the telomerase. Due to its ability to maintain telomere length, the telomerase slows down and possibly suspends the aging of the cells. In regard to this, solid evidence demonstrates that female human fertility decreases with increased maternal age and that various adverse factors, including alterations in telomerase activity, can contribute to age-associated infertility in women. The fact that telomerase activity is regulated in a time- and location-dependent manner in both embryo and placental tissues, highlights it potential importance to the successful completion of pregnancy. Since maternal age is a crucial determining factor for the success of in vitro and in vivo fertilization, numerous studies have focused on telomerase activity and its correlation with mammalian fertilization, as well as the following cleavage and pre-implantation developmental processes. Associations between telomerase activity and pregnancy complications have been previously observed. Our aim in this review was to summarize and critically discuss evidence correlating telomerase activity with pregnancy complications.

Malnutrition and Childhood Disability in Turkana, Kenya: Results from a Case-Control Study

BACKGROUND

Children with disabilities may be particularly vulnerable to malnutrition, as a result of exclusions and feeding difficulties. However, there is limited evidence currently available on this subject.

METHODS

A population-based case-control study was conducted in Turkana County, Kenya, between July and August 2013. Key informants in the community identified children aged 6 months to 10 years who they believed may have a disability. These children were screened by a questionnaire (UNICEF-Washington Group) and assessed by a paediatrician to confirm whether they had a disability and the type. Two controls without disabilities were selected per case: A sibling control (sibling nearest in age) and a neighbourhood control (nearest neighbour within one year of age). The caregiver completed a questionnaire on behalf of the child (e.g. information on feeding, poverty, illness, education), and anthropometric measures were taken. We undertook multivariable logistic and linear regression analyses to estimate the relationship between disability and malnutrition.

RESULTS

The study included 311 cases with disabilities, 196 sibling controls and 300 neighbour controls. Children with disabilities were more likely to report a range of feeding difficulties. They were 1.6-2.9 times more likely to have malnutrition in comparison to neighbour controls or family controls, including general malnutrition (low weight for age), stunting (low height for age), low body mass index (BMI) or low mid upper arm circumference (MUAC) for age. Children with disabilities were almost twice as likely to have wasting (low weight for height) in comparison to neighbour controls (OR = 1.9, 95% CI 1.1-3.2), but this difference was not apparent compared with siblings (OR = 1.5, 95% CI 0.8-2.7). Children with disabilities also faced other exclusions. For instance those aged 5+ were much more likely not to attend school than neighbour controls (OR = 8.5, 95% CI 4.3-16.9).

CONCLUSIONS

Children with disabilities were particularly vulnerable to malnutrition, even within this area of food insecurity and widespread malnutrition. Efforts need to be made to include children with disabilities within food supplementation programmes, and school based programmes alone may be inadequate to meet this need. Exclusion of children with disabilities from education is also a priority area to be addressed.

Regional research priorities in brain and nervous system disorders

The characteristics of neurological, psychiatric, developmental and substance-use disorders in low- and middle-income countries are unique and the burden that they have will be different from country to country. Many of the differences are explained by the wide variation in population demographics and size, poverty, conflict, culture, land area and quality, and genetics. Neurological, psychiatric, developmental and substance-use disorders that result from, or are worsened by, a lack of adequate nutrition and infectious disease still afflict much of sub-Saharan Africa, although disorders related to increasing longevity, such as stroke, are on the rise. In the Middle East and North Africa, major depressive disorders and post-traumatic stress disorder are a primary concern because of the conflict-ridden environment. Consanguinity is a serious concern that leads to the high prevalence of recessive disorders in the Middle East and North Africa and possibly other regions. The burden of these disorders in Latin American and Asian countries largely surrounds stroke and vascular disease, dementia and lifestyle factors that are influenced by genetics. Although much knowledge has been gained over the past 10 years, the epidemiology of the conditions in low- and middle-income countries still needs more research. Prevention and treatments could be better informed with more longitudinal studies of risk factors. Challenges and opportunities for ameliorating nervous-system disorders can benefit from both local and regional research collaborations. The lack of resources and infrastructure for health-care and related research, both in terms of personnel and equipment, along with the stigma associated with the physical or behavioural manifestations of some disorders have hampered progress in understanding the disease burden and improving brain health. Individual countries, and regions within countries, have specific needs in terms of research priorities.

Slow Physical Growth, Delayed Reflex Ontogeny, and Permanent Behavioral as Well as Cognitive Impairments in Rats Following Intra-generational Protein Malnutrition

Environmental stressors including protein malnutrition (PMN) during pre-, neo- and post-natal age have been documented to affect cognitive development and cause increased susceptibility to neuropsychiatric disorders. Most studies have addressed either of the three windows and that does not emulate the clinical conditions of intra-uterine growth restriction (IUGR). Such data fail to provide a complete picture of the behavioral alterations in the F1 generation. The present study thus addresses the larger window from gestation to F1 generation, a new model of intra-generational PMN. Naive Sprague Dawley (SD) dams pre-gestationally switched to LP (8% protein) or HP (20% protein) diets for 45 days were bred and maintained throughout gestation on same diets. Pups born (HP/LP dams) were maintained on the respective diets post-weaningly. The present study aimed to show the sex specific differences in the neurobehavioral evolution and behavioral phenotype of the HP/LP F1 generation pups. A battery of neurodevelopmental reflex tests, behavioral (Open field and forelimb gripstrength test), and cognitive [Elevated plus maze (EPM) and Morris water maze (MWM)] assays were performed. A decelerated growth curve with significantly restricted body and brain weight, delays in apparition of neuro-reflexes and poor performance in the LP group rats was recorded. Intra-generational PMN induced poor habituation-with-time in novel environment exploration, low anxiety and hyperactive like profile in open field test in young and adult rats. The study revealed poor forelimb neuromuscular strength in LP F1 pups till adulthood. Group occupancy plots in MWM test revealed hyperactivity with poor learning, impaired memory retention and integration, thus modeling the signs of early onset Alzehemier phenotype. In addition, a gender specific effect of LP diet with severity in males and favoring female sex was also noticed.