Nutritional status of preschool Senegalese children: long-term effects of early severe malnutrition

A cluster-randomized trial of water, sanitation, handwashing and nutritional interventions on stress and epigenetic programming

A regulated stress response is essential for healthy child growth and development trajectories. We conducted a cluster-randomized trial in rural Bangladesh (funded by the Bill & Melinda Gates Foundation, ClinicalTrials.gov NCT01590095) to assess the effects of an integrated nutritional, water, sanitation, and handwashing intervention on child health. We previously reported on the primary outcomes of the trial, linear growth and caregiver-reported diarrhea. Here, we assessed additional prespecified outcomes: physiological stress response, oxidative stress, and DNA methylation (N = 759, ages 1-2 years). Eight neighboring pregnant women were grouped into a study cluster. Eight geographically adjacent clusters were block-randomized into the control or the combined nutrition, water, sanitation, and handwashing (N + WSH) intervention group (receiving nutritional counseling and lipid-based nutrient supplements, chlorinated drinking water, upgraded sanitation, and handwashing with soap). Participants and data collectors were not masked, but analyses were masked. There were 358 children (68 clusters) in the control group and 401 children (63 clusters) in the intervention group. We measured four F2-isoprostanes isomers (iPF(2α)-III; 2,3-dinor-iPF(2α)-III; iPF(2α)-VI; 8,12-iso-iPF(2α)-VI), salivary alpha-amylase and cortisol, and methylation of the glucocorticoid receptor (NR3C1) exon 1F promoter including the NGFI-A binding site. Compared with control, the N + WSH group had lower concentrations of F2-isoprostanes isomers (differences ranging from -0.16 to -0.19 log ng/mg of creatinine, P < 0.01), elevated post-stressor cortisol (0.24 log µg/dl; P < 0.01), higher cortisol residualized gain scores (0.06 µg/dl; P = 0.023), and decreased methylation of the NGFI-A binding site (-0.04; P = 0.037). The N + WSH intervention enhanced adaptive responses of the physiological stress system in early childhood.

Does money matter for child nutrition? Exploration of a preschool nutrition program in rural South-Central China

OBJECTIVES

The aim of this study was to examine the relationship between poverty and children's nutritional outcomes.

METHODS

Drawing on a 2018 survey of the preschool nutrition program conducted in the Xiangxi Autonomous Prefecture, Hunan Province, China, we applied propensity score matching to estimate the average treatment effects on the treated children.

RESULTS

The most striking result was that although poverty is often used as predictive of poor childhood nutrition, this effect was only significant for weight-for-age z-score and height-for-age z-score, but not for other nutritional indicators, cognition, or social emotional indexes. The results varied using different measures of poverty. The weak linkage between poverty and children's nutritional outcomes was confirmed by a series of robustness checks by changing the covariates for matching, adopting other matching methods, using bootstrapping standard errors, and building on machine learning tools.

CONCLUSIONS

A single tool of small money transfer would have limited effects, but considerable income increases that lift the poor out of poverty are important for the poor. Additionally, a mixed tool of financial support and nutritional knowledge may lead to better outcomes, especially for those living above the poverty line.

Severe malnutrition or famine exposure in childhood and cardiometabolic non-communicable disease later in life: a systematic review

INTRODUCTION

Child malnutrition (undernutrition) and adult non-communicable diseases (NCDs) are major global public health problems. While convincing evidence links prenatal malnutrition with increased risk of NCDs, less is known about the long-term sequelae of malnutrition in childhood. We therefore examined evidence of associations between postnatal malnutrition, encompassing documented severe childhood malnutrition in low/middle-income countries (LMICs) or famine exposure, and later-life cardiometabolic NCDs.

METHODS

Our peer-reviewed search strategy focused on 'severe childhood malnutrition', 'LMICs', 'famine', and 'cardiometabolic NCDs' to identify studies in Medline, Embase, Global Health, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. We synthesised results narratively and assessed study quality with the UK National Institute for Health and Care Excellence checklist.

RESULTS

We identified 57 studies of cardiometabolic NCD outcomes in survivors of documented severe childhood malnutrition in LMICs (n=14) and historical famines (n=43). Exposure to severe malnutrition or famine in childhood was consistently associated with increased risk of cardiovascular disease (7/8 studies), hypertension (8/11), impaired glucose metabolism (15/24) and metabolic syndrome (6/6) in later life. Evidence for effects on lipid metabolism (6/11 null, 5/11 mixed findings), obesity (3/13 null, 5/13 increased risk, 5/13 decreased risk) and other outcomes was less consistent. Sex-specific differences were observed in some cohorts, with women consistently at higher risk of glucose metabolism disorders and metabolic syndrome.

CONCLUSION

Severe malnutrition or famine during childhood is associated with increased risk of cardiometabolic NCDs, suggesting that developmental plasticity extends beyond prenatal life. Severe malnutrition in childhood thus has serious implications not only for acute morbidity and mortality but also for survivors' long-term health. Heterogeneity across studies, confounding by prenatal malnutrition, and age effects in famine studies preclude firm conclusions on causality. Research to improve understanding of mechanisms linking postnatal malnutrition and NCDs is needed to inform policy and programming to improve the lifelong health of severe malnutrition survivors.

Pesticide Exposure and Stunting among Children in Agricultural Areas

Background:

The prevalence of growth disorders among school-aged children in Indonesia is high (30.7%). Pesticides have been massively used in Indonesian agricultural areas.

Objective:

Objective: To determine if exposure to pesticides is associated with stunting among children in agricultural areas.

Methods:

This case-control study included 160 children (48 cases and 112 controls) aged 8–12 years. Exposure to pesticides was measured based on the history of the exposure since perinatal period, infancy, and childhood of the participants. Stunting was determined as a height for age z-score (HAZ) < -2 SD. Other variables measured were levels of thyroid stimulating hormone (TSH), insulin-like growth factor-1 (IGF-1), hemoglobin, zinc, albumin, nutrient adequacy level (energy and protein), and history of infection, low-birth weight (LBW), and mother's height.

Results:

There were no significant difference between the cases and controls in terms of in the baseline characteristics, except for the median IGF-1 level; it was significantly (p<0.001) lower in the cases (66.73 ng/mL) than the controls (112.57 ng/mL). High level of pesticide exposure (p=0.029) and low IGF-1 levels (p<0.001) were significantly associated with stunting. After adjusting for confounding variables, these variables were found to be independent risk factors for stunting in children (aOR 3.90, 95% CI 1.15 to 13.26; and aOR 8.35, 95% CI 3.65 to 19.14, respectively).

Conclusion:

Pesticide exposure could be a risk factor for the occurrence of growth disorders in children living in agricultural areas. Necessary actions should be taken to protect children living in agricultural areas from exposure to pesticides.

Follow-up between 6 and 24 months after discharge from treatment for severe acute malnutrition in children aged 6-59 months: A systematic review

BACKGROUND

Severe acute malnutrition (SAM) is a major global health problem affecting some 16.9 million children under five. Little is known about what happens to children 6-24 months post-discharge as this window often falls through the gap between studies on SFPs and those focusing on longer-term effects.

METHODS

A protocol was registered on PROSPERO (PROSPERO 2017:CRD42017065650). Embase, Global Health and MEDLINE In-Process and Non-Indexed Citations were systematically searched with terms related to SAM, nutritional intervention and follow-up between June and August 2017. Studies were selected if they included children who experienced an episode of SAM, received a therapeutic feeding intervention, were discharged as cured and presented any outcome from follow-up between 6-24 months later.

RESULTS

3,691 articles were retrieved from the search, 55 full-texts were screened and seven met the inclusion criteria. Loss-to-follow-up, mortality, relapse, morbidity and anthropometry were outcomes reported. Between 0.0% and 45.1% of cohorts were lost-to-follow-up. Of those discharged as nutritionally cured, mortality ranged from 0.06% to 10.4% at an average of 12 months post-discharge. Relapse was inconsistently defined, measured, and reported, ranging from 0% to 6.3%. Two studies reported improved weight-for-height z-scores, whilst three studies that reported height-for-age z-scores found either limited or no improvement.

CONCLUSIONS

Overall, there is a scarcity of studies that follow-up children 6-24 months post-discharge from SAM treatment. Limited data that exists suggest that children may exhibit sustained vulnerability even after achieving nutritional cure, including heightened mortality and morbidity risk and persistent stunting. Prospective cohort studies assessing a wider range of outcomes in children post-SAM treatment are a priority, as are intervention studies exploring how to improve post-SAM outcomes and identify high-risk children.

Environmental enteropathy is associated with cardiometabolic risk factors in Peruvian children

Environmental enteropathy (EE) is a syndrome of altered small intestine structure and function hypothesized to be common among individuals lacking access to improved water and sanitation. There are plausible biological mechanisms, both inflammatory and non-inflammatory, by which EE may alter the cardiometabolic profile. Here, we test the hypothesis that EE is associated with the cardiometabolic profile among young children living in an environment of intense enteropathogen exposure. In total, 156 children participating in the Peruvian cohort of a multicenter study on childhood infectious diseases, growth and development were contacted at 3-5 years of age. The urinary lactulose:mannitol ratio, and plasma antibody to endotoxin core were determined in order to assess intestinal permeability and bacterial translocation. Blood pressure, anthropometry, fasting plasma glucose, insulin, and cholesterol and apolipoprotein profiles were also assessed. Extant cohort data were also used to relate biomarkers of EE during the first 18 months of life to early child cardiometabolic profile. Lower intestinal surface area, as assessed by percent mannitol excretion, was associated with lower apolipoprotein-AI and lower high-density lipoprotein concentrations. Lower intestinal surface area was also associated with greater blood pressure. Inflammation at 7 months of age was associated with higher blood pressure in later childhood. This study supports the potential for a relationship between EE and the cardiometabolic profile.

Anthropometric and micronutrient status of school-children in an urban West Africa setting: a cross-sectional study in Dakar (Senegal)

BACKGROUND

Urban areas in West Africa are not immune to undernutrition with recent urbanization and high food prices being important factors. School children often have a poor nutritional status, potentially affecting their health and schooling performance. Yet, generally school children do not benefit from nutrition programs. The objective of the study was to assess the anthropometric and micronutrient status of children from state schools in the Dakar area.

METHODS

School children (n = 604) aged from 5 to 17 y (52.5% girls, 47.5% ≥ 10 y) were selected through a two-stage random cluster sample of children attending urban primary state schools in the Dakar area (30 schools × 20 children). The prevalence of stunting (height-for-age<-2 z-scores) and thinness (BMI-for-age<-2 z-scores, WHO 2006, and three grades of thinness corresponding to BMI of 18.5, 17.0 and 16.0 kg/m2 in adults) were calculated from weight and height. Hemoglobin, plasma concentrations of ferritin (FER), transferrin receptors (TfR), retinol binding protein (RBP), and zinc, and urinary iodine concentrations were measured. Correction factors were used for FER and RBP in subjects with inflammation determined with C-reactive protein and α1-acid-glycoprotein.

RESULTS

4.9% of children were stunted, 18.4% were thin, 5.6% had severe thinness (BMI-for-age<-3 z-scores). Only one child had a BMI-for-age>2 z-scores. Prevalence of anemia, iron deficiency and iron deficiency anemia was 14.4%, 39.1% and 10.6% respectively. 3.0% had vitamin A deficiency, 35.9% a marginal vitamin A status, and 25.9% zinc deficiency. Urinary iodine was <50 µg/L in 7.3% of children and ≥ 200 µg/L in 22.3%. The prevalence of marginal vitamin A, zinc deficiency, high TfR was significantly higher in boys than in girls (P<0.05). Height-for-age and retinol were significantly lower in participants ≥ 10 y and <10 y respectively.

CONCLUSION

Undernutrition, especially thinness, iron and zinc deficiencies in school children in the Dakar area requires special targeted nutrition interventions.

Hepatoprotective and nephroprotective effects of Cnidoscolus aconitifolius in protein energy malnutrition induced liver and kidney damage

Introduction:

This study was designed to evaluate the ameliorative and hypocholesterolemic effects of dietary supplementation of Cnidoscolus aconitifolius leaf meal (CALM) on hepatic injury and kidney injury associated with protein energy malnutrition (PEM).

Materials and Methods:

In this study, PEM was induced in weaning male Wistar albino rats by feeding them with low protein diet for 2 weeks. The effects of several recovery diets containing 20% soya protein or 20% C. aconitifolius in place of soya protein or 10% soya proteins with 10% C. aconitifolius or commercial rat feed were assessed in PEM rats. Plasma biochemical parameters were assessed as well.

Results:

After the induction of PEM, results obtained showed significant increase in alkaline phosphatase (ALP), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total proteins (T.P), total bilirubin (T.Bil), triglycerides, total cholesterol, low density lipoproteins (LDL), blood urea nitrogen (BUN), and creatinine with significant reduction in plasma high density lipoproteins (HDL), albumin, sodium (Na⁺), potassium (K⁺), chloride (Cl⁻), bicarbonate (HC03⁻), and phosphate (P04²⁻) in PEM rats. Upon introduction of recovery diets containing 20% soya protein or 20% C. aconitifolius in place of soya protein or 10% soya proteins with 10% C. aconitifolius or commercial rat feed for 4 weeks caused significant (P < 0.05) reduction in plasma values of ALP, ALT, AST, T.bil, T.P., LDL, total cholesterol, triglycerides, BUN, creatinine, and significant increase in HDL and complete restoration of plasma electrolytes.

Conclusions:

C. aconitifolius in protein deficient diets has a protective role against hepatic injury and renal damage associated with PEM.

Human IGF1 extends lifespan and enhances resistance to Plasmodium falciparum infection in the malaria vector Anopheles stephensi

The highly conserved insulin/insulin-like growth factor (IGF) signaling (IIS) pathway regulates metabolism, development, lifespan and immunity across a wide range of organisms. Previous studies have shown that human insulin ingested in the blood meal can activate mosquito IIS, resulting in attenuated lifespan and increased malaria parasite infection. Because human IGF1 is present at higher concentrations in blood than insulin and is functionally linked with lifespan and immune processes, we predicted that human IGF1 ingested in a blood meal would affect lifespan and malaria parasite infection in the mosquito Anopheles stephensi. Here we demonstrate that physiological levels of ingested IGF1, like insulin, can persist intact in the blood-filled midgut for up to 30 h and disseminate into the mosquito body, and that both peptides activate IIS in mosquito cells and midgut. At these same levels, ingested IGF1 alone extended average mosquito lifespan by 23% compared with controls and, more significantly, when ingested in infected blood meals, reduced the prevalence of Plasmodium falciparum-infected mosquitoes by >20% and parasite load by 35-50% compared with controls. Thus, the effects of ingested IGF1 on mosquito lifespan and immunity are opposite to those of ingested insulin. These results offer the first evidence that insect cells can functionally discriminate between mammalian insulin and IGF1. Further, in light of previous success in genetically targeting IIS to alter mosquito lifespan and malaria parasite transmission, this study indicates that a more complete understanding of the IIS-activating ligands in blood can be used to optimize transgenic strategies for malaria control.

Language skills and intelligence quotient of protein energy malnutrition survivors

The study was conducted on 33 children aged 3-6 years who suffered from protein energy malnutrition (PEM) during infancy in comparison to 30 matching children to assess the long-term deficits in cognition and language skills. The patients' files were revised to record their admission and follow-up data and history, clinical examination, intelligence quotient and language assessment were done. The study revealed that 2-5 years from the acute attack the PEM patients were still shorter than the controls and their cognitive abilities were poorer. Their mental ages and language skills were mostly determined by their height and the duration of follow-up during their acute illness. Additionally their diet after the 3-5 years is still defective and does not meet their recommended daily allowance. These observations urge us to continue following these patients for longer durations to make sure no permanent damage occurs due to the PEM insult to the growing brain.

Situational analysis of infant and young child nutrition policies and programmatic activities in Senegal

Progress towards reducing mortality and malnutrition among children <5 years of age has been less than needed to achieve related Millennium Development Goals (MDGs). Therefore, several international agencies joined to 'Reposition children's right to adequate nutrition in the Sahel', starting with an analysis of current activities related to infant and young child nutrition (IYCN). The main objectives of the situational analysis are to compile, analyse and interpret available information on infant and child feeding and the nutrition situation of children <2 years of age in Senegal, as one of the six targeted countries. These findings will be used to assist in identifying inconsistencies and filling gaps in current programming. Between August and December 2008, key informants responsible for conducting IYCN-related activities in Senegal were interviewed, and 157 documents were examined on the following themes: optimal breastfeeding and complementary feeding practices, prevention of micronutrient deficiencies, prevention of mother-to-child transmission of HIV, management of acute malnutrition, food security and hygienic practices. Nearly all of the key IYCN topics were addressed, specifically or generally, in national policy documents. Senegal reported substantial improvements since the 1990s towards reducing infant and young child mortality and underweight, and increasing exclusive breastfeeding among infants <6 months of age (34%). Senegal is one of the few countries in the region that is nearly on track for reaching related MDGs. Notable activities that may have played a role include: (1) vitamin A supplementation was expanded to nearly semi-annual national campaigns starting in 1994; (2) the Ministry of Health partnered with several national and international agencies to scale up child survival activities under the umbrella of the Basic Support for Institutionalizing Child Survival (1994-2006); (3) a national nutrition division was developed to support a national nutrition strengthening programme; (4) the national nutrition counsel was organized to coordinate nutritional activities across various organizations and governmental sectors, involving representatives from health, agriculture and surveillance; and (5) an integrated communications programme was developed to support harmonized behaviour change communication tools for the health and nutrition sectors. Along with these activities, a number of programme evaluations were conducted to ensure that programmes obtain desired results. Although useful, these evaluations were not rigorous enough to identify effective programmes that contributed to the mentioned reductions in the prevalence of underweight and mortality, and increases in exclusive breastfeeding. The policy and programme framework is well established for support of optimal IYCN practices in Senegal. Despite the recent improvements in infant and young child nutritional status indicators, there is still much to do. Greater resources and continued capacity building are needed to: (1) conduct necessary research for adapting training materials and programme protocols to programmatic needs; (2) improve and carry out monitoring and evaluation that identify effective programme components; and (3) apply these findings in developing, expanding and improving effective programmes.

Glucose-responsive gene expression system for gene therapy

Regulation of gene expression by glucose is an important mechanism for mammals in adapting to their nutritional environment. Glucose, the primary fuel for most cells, modulates gene expression that is crucial in the cellular adaptation to glycemic variation. Transcription of the genes for insulin and glycolytic and lipogenic enzymes is stimulated by glucose in pancreatic beta-cells and liver. Recent findings further support the key role of the carbohydrate-responsive element binding protein in the regulation of glycolytic and lipogenic genes by glucose and dietary carbohydrates. Herein, we review the transcriptional regulation of glucose-responsive genes, and recent advances in the gene therapy using glucose-responsive gene expression for diabetes.

Impact of long-term oral iron supplementation in breast-fed infants

OBJECTIVE

To weigh benefits of oral iron supplements on infant's growth against its potential hazards.

METHODS

248 exclusively breast-fed infants aged 4-6 months were consecutively enrolled and divided into treatment group given iron containing multivitamin (TG = 198) and control group (placebo, PG = 50) given the same multivitamin but without is subdivided according to clinical assessment into group A (well nourished) and group B (malnourished); both were further stratified according to basal blood iron status. Assessment was done after 6 and 12 months with concurrent collection of morbidity parameters (diarrhea and fever). Data were normalized and analyzed using SPSS and Eurogrowth softwares.

RESULTS

After 6 months treatment, weight and length gain was better in TG compared to placebo especially evident in anemic malnourished infants (P 0.05). Morbidity risk was linked to immunologic background of infant; odds ratio for diarrhea and fever was higher in malnourished compared to well nourished (P 0.05) or iron therapy (P for well-nourished non-anemic treatment vs PG > 0.05).

CONCLUSION

Oral iron supplementation resulted in better effects on growth velocity of breast fed infants especially those who were initially malnourished and anemic or at least iron depleted, with less marked morbidity than in iron replete infants.

Association between insulin-like growth factor-1, insulin-like growth factor-binding protein-1 and leptin levels with nutritional status in 1–3-year-old children, residing in the central region of Limpopo Province, South Africa

The present study evaluated levels of growth factors and their associations with nutritional status with emphasis on stunting in children at 1 and 3 years of age. A follow-up study on a birth cohort (n 219) of children from villages in the central region of the Limpopo Province was undertaken. Of the original cohort, 156 and 162 could be traced and assessed at ages 1 and 3 years, respectively. Data collected included socio-demographic characteristics, anthropometric measurements, dietary intake and fasting blood (collected from 116 and 145 children at 1 and 3 years, respectively) for growth factor analysis (insulin-like growth factor (IGF)-1, IGF binding protein (BP)-1, IGFBP-3, leptin, glucose and insulin). At 1 year it was found that stunted children had lower leptin levels while their IGFBP-1 levels were higher than that in normal children. These differences were, however, not observed at 3 years. Furthermore at 1 year the biochemical parameters were more related to length measures whereas at 3 years the parameters were more associated with weight measures. The observed stunting in this group of children may be a result of chronic undernutrition resulting in long-term growth faltering which is already evident at 1 year. Thus the observed phenomenon might be an adaptive mechanism adopted by children's metabolic processes as they grow up in an environment with inadequate essential nutrients due to poor weaning practices and consumption of a diet of poor quality, resulting in them gaining more weight at the expense of linear growth.

Long-term effect of early protein malnutrition on growth curve, hematological parameters and macrophage function of rats

To evaluate the long-term effect of mild-early maternal protein malnutrition on weight gain, hematological parameters and macrophage function in rats at adult age, we compared rats whose dams were fed diets containing either 9.5% (low protein-LPD) or 23% protein (normal-NPD) for the first 12 d of lactation. At 80 d of age, the functions of spreading, phagocytosis and killing Candida albicans were determined in resident peritoneal macrophages, whereas leukocytes and red blood cells were counted in peripheral blood. The number of resident peritoneal macrophages from LPD was the same as from NPD, but the ability of spreading and phagocytosing opsonised yeast was impaired. Besides, they were not able to block the germ tube formation or kill C. albicans to the same extent as in the control group. The low protein diet produced a significant reduction in the pups' growth and in hematological parameters although no difference was found in leukocyte counts. Taken together the data suggest that protein malnutrition during early lactation induces permanent alterations in macrophage function, body composition and hematological status, which are not restored completely even after a normal protein diet is supplied.

Critical appraisal of the management of severe malnutrition: 3. Complications

The high case-fatality of severe malnutrition is due to infections, dehydration, electrolyte disturbances and heart failure. We focus on the evidence about managing these complications of severe malnutrition. Signs of circulatory collapse in severely malnourished children should be treated with intravenous or bone marrow infusion of Ringer's lactate with additional dextrose and potassium at a rate 20-40 mL/kg fast with close monitoring of vital signs. Recommendations for slow or restricted fluids in the face of shock are unsafe, and hypotonic or maintenance solutions must be avoided to prevent hyponatraemia. However, the evidence that severely malnourished children do not tolerate excessive fluid administration is good, so caution must be exercised with regards to fluids in the initial phase of treatment. There is also good evidence that wide spectrum antibiotics need to be given empirically for severe malnutrition to prevent the otherwise unavoidable early mortality. There is a need for improved protocols for tuberculosis diagnosis, HIV management and treatment of infants under 6 months with severe malnutrition. The contribution of environmental enteropathy to poor growth and nutrition during the weaning period means that there should be more priority on improving environmental health, particularly better hygiene and less overcrowding. A T-cell mediated enteropathy contributes to growth failure and malnutrition, and it is related to environmental contamination of enteric organisms in the weaning period rather than allergic responses.

Serum prealbumin and albumin concentrations do not reflect nutritional state in children with cerebral palsy

Serum prealbumin concentration (PALB) and albumin concentration (ALB) were evaluated as markers of undernutrition in 107 children with cerebral palsy (CP) age 2 to 18 years. PALB and ALB were rarely below the normal reference ranges and showed little to no correlation with anthropometric measures (eg, skinfolds, midarm fat area), growth (height), severity of CP (eg, feeding dysfunction, motor impairment), or general health.