Severe acute malnutrition in childhood, chronic diseases, and human capital in adulthood in the Democratic Republic of Congo: the Lwiro Cohort Study

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Exploring the determinants of malnutrition in 2-5 year Iranian children using structural equation modeling: national food and nutrition surveillance

BACKGROUND

Childhood malnutrition remains a critical public health challenge in low- and middle-income countries, contributing significantly to morbidity and mortality among children aged 2-5 years. This study was undertaken to assess the nutritional status of 2-5 y children and to explore the main determinants of child malnutrition in eight food insecure provinces of Iran.

METHODS

In each province, participants were invited to attend the health house/center to complete the questionnaire on the pre-appointed day. In this study, an android application comprising electronic questionnaires was employed for data collection. Anthropometric, dietary, food security and socioeconomic status (SES) assessments were performed. Structural equation modeling (SEM) was done to assess the structural relationship of malnutrition indicators (z-score of height to age (HAZ), z-score of weight to age (WAZ) and z-score of weight to height (WHZ)) with other variables.

RESULTS

Overall, 2247 children aged 42.2 ± 0.3 months were enrolled in the study, of whom 1048 (46.6%) were female and 1438 (64%) were urban residents. Based on Z score criteria, 216 (10.1%) of the studied children had less than - 2SD HAZ, 193 (8.4%) had lower than - 2SD WHZ and 188 (8.1%) had lower than - 2SD WAZ. The prevalence rates of stunting, wasting and underweight were not significantly different between boys and girls. Nevertheless, the occurrence of stunting was significantly higher in children residing in rural than in urban areas (p = 0.025). SEM analysis revealed that higher SES had a positive relationship with HAZ (0.089), WAZ (0.163) and WHZ (0.109). The effect of SES was greatest on WAZ, indicated by the highest absolute value of a path coefficient. There were specific indirect effects of father's education on HAZ (0.032, p = 0.001), WHZ (0.045, < 0.001) and WAZ (0.061, < 0.001) through effect on SES and DDS. SES had a direct effect on DDS (0.202).

CONCLUSIONS

Our findings using SEM approach provided more concrete evidence for the effect of the household's SES on child's nutritional status. Nevertheless, we still need to monitor the studied population in the context of our surveillance program to document more conclusive causal associations.

Guardians under pressure, a spotlight on hypertension among healthcare workers in Kinshasa, Democratic Republic of Congo: a cross-sectional study

BACKGROUND

Hypertension is one of the main risk factors for cardiovascular disease impacting over a billion people worldwide. Work environment factors could adversely affect workers' cardiovascular health, including contributing to hypertension. Healthcare workers who treat patients are also affected. In the Democratic Republic of Congo, limited studies explored the work environment factors associated with hypertension. This study aimed to examine hypertension prevalence and determine the associated risk factors among healthcare workers in Kinshasa.

METHODS

A cross-sectional study was conducted in Kinshasa's healthcare facilities from December 2023 to January 2024 among healthcare workers selected by multistage stratified random sampling. Data was collected through a structured questionnaire using a modified WHO STEPwise approach and Karasek questionnaire. Anthropometric parameters, blood pressure, and fasting blood sugar were measured. The prevalence of hypertension was assessed. All sociodemographic, occupational, and lifestyle variables associated with hypertension were included in multivariable logistic regression analysis at the 5% significance level.

RESULTS

The study encompassed 614 participants, comprising 55.2% females and 44.8% males. The mean age of participants was 38.8 ± 10.4 years, ranging from 20 to 78 years. The prevalence of hypertension was 22.6% and over half of those with hypertension (56.1%) were unaware of their condition. Of the known hypertensive participants before the study, 60.7% had uncontrolled blood pressure. In the multivariable analysis, identified risk factors for hypertension were age ≥ 40 years (aOR = 2.75, 95% CI: 1.64-4.61), seniority ≥ 10 years (aOR = 2.65, 95% CI: 1.54-4.58), multiple job holding (aOR = 3.11, 95% CI: 1.81-5.34), job stress (aOR = 1.84, 95% CI: 1.17-2.89), physical inactivity (aOR = 1.67, 95% CI: 1.03-2.68), overweight (aOR = 1.75, 95% CI: 1.06-2.90) and obesity (aOR = 3.75, 95% CI: 2.10-6.70).

CONCLUSION

Our results underline an important prevalence of hypertension among healthcare workers in Kinshasa, despite their medical knowledge of the causes and the risks. A healthy lifestyle among healthcare workers is fundamental for ensuring the efficiency and productivity of the healthcare system. Regulating multiple job holding and implementing a hypertension prevention intervention encompassing their holistic support is crucial for reducing job stress and promoting well-being.

Long-term outcomes after severe childhood malnutrition in adolescents in Malawi (LOSCM): a prospective observational cohort study

BACKGROUND

Research on long-term outcomes of severe childhood malnutrition is scarce. Existing evidence suggests potential associations with cardiometabolic disease and impaired cognition. We aimed to assess outcomes in adolescents who were exposed to severe childhood malnutrition compared with peers not exposed to severe childhood malnutrition.

METHODS

In Long-term Outcomes after Severe Childhood Malnutrition (LOCSM), we followed up adolescents who had 15 years earlier received treatment for severe childhood malnutrition at Queen Elizabeth Central Hospital in Blantyre, Malawi. Adolescents with previous severe childhood malnutrition included in LOCSM had participated in an earlier follow-up study (ChroSAM) at 7 years after treatment for severe childhood malnutrition, where they were compared to siblings and age-matched children in the community without previous severe childhood malnutrition. We measured anthropometry, body composition, strength, glucose tolerance, cognition, behaviour, and mental health during follow-up visits between Sept 9, 2021, and July 22, 2022, comparing outcomes in adolescents exposed to previous severe childhood malnutrition with unexposed siblings and adolescents from the community assessed previously (for ChroSAM) and newly recruited during current follow-up. We used a linear regression model to adjust for age, sex, disability, HIV, and socioeconomic status. This study is registered with the International Standard Randomised Controlled Trial Number Registry (ISRCTN17238083).

FINDINGS

We followed up 168 previously malnourished adolescents (median age 17·1 years [IQR 16·5 to 18·0]), alongside 123 siblings (18·2 years [15·0 to 20·5]), and 89 community adolescents (17·1 years [16·3 to 18·1]). Since last measured 8 years previously, mean height-for-age Z (HAZ) scores had improved in previously malnourished adolescents (difference 0·33 [95% CI 0·20 to 0·46]) and siblings (0·32 [0·09 to 0·55]), but not in community adolescents (difference -0·01 [-0·24 to 0·23]). Previously malnourished adolescents had sustained lower HAZ scores compared with siblings (adjusted difference -0·32 [-0·58 to -0·05]) and community adolescents (-0·21 [-0·52 to 0·10]). The adjusted difference in hand-grip strength between previously malnourished adolescents and community adolescents was -2·0 kg (-4·2 to 0·3). For child behaviour checklist internalising symptom scores, the adjusted difference for previously malnourished adolescents was 2·8 (0·0 to 5·5) compared with siblings and 2·1 (-0·1 to 4·3) compared with community adolescents. No evidence of differences between previously malnourished adolescents and unexposed groups were found in any of the other variables measured.

INTERPRETATION

Catch-up growth into adolescence was modest compared with the rapid improvement seen in childhood, but provides optimism for ongoing recovery of height deficits. We found little evidence of heightened non-communicable disease risk in adolescents exposed to severe childhood malnutrition, although long-term health implications need to be monitored. Further investigation of associated home and environmental factors influencing long-term outcomes is needed to tailor preventive and treatment interventions.

FUNDING

The Wellcome Trust.

Post-malnutrition growth and its associations with child survival and non-communicable disease risk: a secondary analysis of the Malawi 'ChroSAM' cohort

OBJECTIVE

To explore patterns of post-malnutrition growth (PMGr) during and after treatment for severe malnutrition and describe associations with survival and non-communicable disease (NCD) risk 7 years post-treatment.

DESIGN

Six indicators of PMGr were derived based on a variety of timepoints, weight, weight-for-age z-score and height-for-age z-score (HAZ). Three categorisation methods included no categorisation, quintiles and latent class analysis (LCA). Associations with mortality risk and seven NCD indicators were analysed.

SETTING

Secondary data from Blantyre, Malawi between 2006 and 2014.

PARTICIPANTS

A cohort of 1024 children treated for severe malnutrition (weight-for-length z-score < 70 % median and/or MUAC (mid-upper arm circumference) < 110 mm and/or bilateral oedema) at ages 5-168 months.

RESULTS

Faster weight gain during treatment (g/d) and after treatment (g/kg/day) was associated with lower risk of death (adjusted OR 0·99, 95 % CI 0·99, 1·00; and adjusted OR 0·91, 95 % CI 0·87, 0·94, respectively). In survivors (mean age 9 years), it was associated with greater hand grip strength (0·02, 95 % CI 0·00, 0·03) and larger HAZ (6·62, 95 % CI 1·31, 11·9), both indicators of better health. However, faster weight gain was also associated with increased waist:hip ratio (0·02, 95 % CI 0·01, 0·03), an indicator of later-life NCD risk. The clearest patterns of association were seen when defining PMGr based on weight gain in g/d during treatment and using the LCA method to describe growth patterns. Weight deficit at admission was a major confounder.

CONCLUSIONS

A complex pattern of benefits and risks is associated with faster PMGr. Both initial weight deficit and rate of weight gain have important implications for future health.

Maternal and paternal employment in agriculture and early childhood development: A cross-sectional analysis of Demographic and Health Survey data

Considerable literature from low- and lower-middle-income countries (LLMICs) links maternal employment to child nutritional status. However, less is known about the role of parental employment and occupation type in shaping child development outcomes. Additionally, little empirical work has examined the mechanisms through which parental occupation influences child outcomes. Our objective was to investigate the associations between maternal and paternal employment (comparing agricultural and non-agricultural employment) and child development and to examine childcare practices and women's empowerment as potential mechanisms. We pooled nine Demographic and Health Surveys (Benin, Burundi, Cambodia, Congo, Haiti, Rwanda, Senegal, Togo, and Uganda) with data on 8,516 children aged 36-59 months. We used generalised linear models to estimate associations between parental employment and child development, child stimulation (number of activities provided by the mother, father, and other household members), child supervision (not left alone or with older child for >1 hour), early childhood care and education programme (ECCE) attendance, and women's empowerment. In our sample, all fathers and 85% of mothers were employed. In 40% of families, both parents were employed in agriculture. After adjusting for child, parental and household confounders, we found that parental agricultural employment, relative to non-agricultural employment, was associated with poorer child development (relative risk (RR) 0.86 (95% CI 0.80, 0.92), more child stimulation provided by other household members (mean difference (MD) 0.26 (95% CI 0.09, 0.42)), less adequate child supervision (RR, 0.83 (95% 0.78, 0.80)), less ECCE attendance (RR 0.46 (95% CI 0.39, 0.54)), and lower women's empowerment (MD -1.01 (95% CI -1.18, -0.84)). Parental agricultural employment may be an important risk factor for early childhood development. More research using more comprehensive exposure and outcome measures is needed to unpack these complex relationships and to inform interventions and policies to support working parents in the agricultural sector with young children.

Anthropometry, body composition and chronic disease risk factors among Zambian school-aged children who experienced severe malnutrition in early childhood

There is limited information as to whether people who experience severe acute malnutrition (SAM) as young children are at increased risk of overweight, high body fat and associated chronic diseases in later life. We followed up, when aged 7-12 years, 100 Zambian children who were hospitalised for SAM before age 2 years and eighty-five neighbourhood controls who had never experienced SAM. We conducted detailed anthropometry, body composition assessment by bioelectrical impedance and deuterium dilution (D2O) and measured blood lipids, Hb and HbA1c. Groups were compared by linear regression following multiple imputation for missing variables. Children with prior SAM were slightly smaller than controls, but differences, controlling for age, sex, socio-economic status and HIV exposure or infection, were significant only for hip circumference, suprailiac skinfold and fat-free mass index by D2O. Blood lipids and HbA1c did not differ between groups, but Hb was lower by 7·8 (95 % CI 0·8, 14·7) g/l and systolic blood pressure was 3·4 (95 % CI 0·4, 6·4) mmHg higher among the prior SAM group. Both anaemia and high HbA1c were common among both groups, indicating a population at risk for the double burden of over- and undernutrition and associated infectious and chronic diseases. The prior SAM children may have been at slightly greater risk than the controls; this was of little clinical significance at this young age, but the children should be followed when older and chronic diseases manifest.

Risk of Chronic Disease after an Episode of Marasmus, Kwashiorkor or Mixed-Type Severe Acute Malnutrition in the Democratic Republic of Congo: The Lwiro Follow-Up Study

Background: Long-term impact of different forms of severe acute malnutrition (SAM) in childhood on the emergence of noncommunicable diseases (NCDs) is poorly known. Aim: To explore the association between subtypes of SAM during childhood, NCDs, and cardiovascular risk factors (CVRFs) in young adults 11 to 30 years after post-SAM nutritional rehabilitation. Methods: In this follow-up study, we investigated 524 adults (mean age 22 years) treated for SAM during childhood in eastern Democratic Republic of the Congo (DRC) between 1988 and 2007. Among them, 142 had a history of marasmus, 175 of kwashiorkor, and 207 had mixed-form SAM. These participants were compared to 407 aged- and sex-matched control adults living in the same community without a history of SAM. Our outcomes of interest were cardiometabolic risk markers for NCDs. Logistic and linear regressions models were sued to estimate the association between subtype of SAM in childhood and risk of NCDs. Results: Compared to unexposed, former mixed-type SAM participants had a higher adjusted ORs of metabolic syndrome [2.68 (1.18; 8.07)], central obesity [1.89 (1.11; 3.21)] and low HDL-C (High-density lipoprotein cholesterol) [1.52 (1.08; 2.62)]. However, there was no difference between groups in terms of diabetes, high blood pressure, elevated LDL-C (low-density lipoprotein cholesterol) and hyper TG (hypertriglyceridemia) and overweightness. Former mixed-type SAM participants had higher mean fasting glucose [3.38 mg/dL (0.92; 7.7)], reduced muscle strength [−3.47 kg (−5.82; −1.11)] and smaller hip circumference [−2.27 cm (−4.24; −0.31)] compared to non-exposed. Regardless of subtypes, SAM-exposed participants had higher HbA1c than unexposed (p < 0.001). Those with a history of kwashiorkor had cardiometabolic and nutritional parameters almost superimposable to those of unexposed. Conclusion: The association between childhood SAM, prevalence of NCDs and their CVRFs in adulthood varies according to SAM subtypes, those with mixed form being most at risk. Multicenter studies on larger cohorts of older participants are needed to elucidate the impact of SAM subtypes on NCDs risk.

Human Milk output among mothers previously treated for severe acute malnutrition in childhood in Democratic Republic of Congo

BACKGROUND

Malnutrition is a public health problem, as wasting affects 7.5% of children worldwide. The harmful effects of severe acute malnutrition (SAM) can last a lifetime, but how SAM in childhood affects later breastfeeding ability is not clear. In the present study, we assessed the human milk output and body composition among mothers with a history of childhood SAM.

METHODS

This retrospective cohort study was carried out in Miti-Murhesa Health Zone (Democratic Republic of Congo) from January 15 to March 17, 2020. We selected lactating mothers with breastfed infants aged 2-12 months. Two categories of mothers were included: those who had been treated for SAM during their childhood (years 1988-2003; n = 39) and a community control with no history of SAM (n = 40). The weight, height, and mid-upper arm circumference were measured and body mass index (BMI) calculated as weight/height2. Body composition and human milk output were assessed using standard deuterium dilution methods. Student t and chi2 tests ware applied to compare two groups.

RESULTS

The mean age ± standard deviation of the mothers was 24.4 ± 5.1 and 26.0 ± 6.1 years for the SAM and control groups, respectively (p = 0.186). The age of their infants was 5.4 ± 2.3 months in both groups (p = 0.962). In the SAM and control groups, the mean maternal BMI was 23.8 ± 2.3 and 23.6 ± 3.7 kg/m2 (p = 0.849), mean Fat Mass 27.1% ± 5.0 and 27.1% ± 5.8% (p = 0.708), and the mean Fat Free mass 72.9% ± 5.0 and 72.9% ± 5.8% (p = 0.998), respectively. Human milk output was 833.7 ± 152.1 g/d in SAM group and 827.4 ± 171.4 g/d in the control group (p = 0.864).

CONCLUSIONS

We found no significant difference in human milk output and body composition in mothers treated for SAM during childhood compared to community controls.

Body composition of adults with a history of severe acute malnutrition during childhood using the deuterium dilution method in eastern DR Congo: the Lwiro Cohort Study

BACKGROUND

Few studies have evaluated the body composition (BC) of adults who suffered from severe acute malnutrition (SAM) during childhood, a population at risk of long-term noncommunicable diseases.

OBJECTIVE

We performed an observational cohort study to evaluate BC in a group of young adults aged 11-30 y after nutritional rehabilitation for SAM, in the Democratic Republic of the Congo (DRC).

METHODS

We evaluated 151 adults in eastern DRC who were treated for SAM during childhood between 1988 and 2007. They were compared with 120 aged- and sex-matched control adults living in the same community who had not been exposed to malnutrition as children. The main variables of interest were the different compartments of adult BC (fat-free mass [FFM], fat mass [FM], and 2 indices of height-normalized BC: FFM index [FFMI] and FM index [FMI]) measured by deuterium dilution.

RESULTS

The mean age in both groups was 23 y, and females represented 49% and 56% of the exposed and nonexposed groups, respectively. SAM-exposed males had lower mean ± SD weight (53.6 ± 6.4 compared with 56.4 ± 7.9 kg, P = 0.029) and lower height (159.9 ± 6.6 compared with 163.6 ± 6.7 cm, P = 0.003) compared to unexposed males. SAM-exposed subjects had less FFM (-1.56 kg [-2.93, -0.20]; P = 0.024) but this observation was more marked in males (45.4 ± 5.4 compared with 48.2 ± 6.9 kg, P = 0.01) than in females. No differences in FM were noted between SAM-exposed and unexposed subjects. Adjusting for height, FFMI and FMI showed no difference between SAM-exposed and unexposed in either sex.

CONCLUSION

SAM during childhood is associated with reduced FFM in adulthood which is probably due to a shorter height.