Infant and young child feeding practices in urban Philippines and their associations with stunting, anemia, and deficiencies of iron and vitamin A

Stunting predictors among children aged 0-24 months in Southeast Asia: a scoping review

OBJECTIVE

To identify predictors of stunting among children 0-24 months in Southeast Asia.

METHODS

This scoping review focused on articles with observational study design in English published from 2012 to 2023 from five international databases. The primary keyword used were: "stunting" OR "growth disorder" AND "newborn" AND "predict" AND "Southeast Asia".

RESULTS

Of the 27 articles selected for the final analysis there are thirteen predictors of stunting in seven Southeast Asia countries. The thirteen predictors include the child, mother, home, inadequate complementary feeding, inadequate breastfeeding, inadequate care, poor quality foods, food and water safety, infection, political economy, health and healthcare, water, sanitation, and environment, and social culture factor.

CONCLUSION

All these predictors can lead to stunting in Southeast Asia. To prevent it, health service providers and other related sectors need to carry out health promotion and health prevention according to the predictors found.

Prelacteal feeding is not associated with infant size at 3 months in rural Bangladesh: a prospective cohort study

BACKGROUND

Early and exclusive breastfeeding may reduce neonatal and post-neonatal mortality in low-resource settings. However, prelacteal feeding (PLF), the practice of giving food or liquid before breastfeeding is established, is still a barrier to optimal breastfeeding practices in many South Asian countries. We used a prospective cohort study to assess the association between feeding non-breastmilk food or liquid in the first three days of life and infant size at 3-5 months of age.

METHODS

The analysis used data from 3,332 mother-infant pairs enrolled in a randomized controlled trial in northwestern rural Bangladesh conducted from 2018 to 2019. Trained interviewers visited women in their households during pregnancy to collect sociodemographic data. Project staff were notified of a birth by telephone and interviewers visited the home within approximately three days and three months post-partum. At each visit, interviewers collected data on breastfeeding practices and anthropometric measures. Infant length and weight measurements were used to produce length-for-age (LAZ), weight-for-age (WAZ), and weight-for-length (WLZ) Z-scores. We used multiple linear regression to assess the association between anthropometric indices and PLF practices, controlling for household wealth, maternal age, weight, education, occupation, and infant age, sex, and neonatal sizes.

RESULTS

The prevalence of PLF was 23%. Compared to infants who did not receive PLF, infants who received PLF may have a higher LAZ (Mean difference (MD) = 0.02 [95% CI: -0.04, 0.08]) score, a lower WLZ (MD=-0.06 [95% CI: -0.15, 0.03]) score, and a lower WAZ (MD=-0.02 [95% CI: -0.08, 0.05]) score at 3-5 months of age, but none of the differences were statistically significant. In the adjusted model, female sex, larger size during the neonatal period, higher maternal education, and wealthier households were associated with larger infant size.

CONCLUSION

PLF was a common practice in this setting. Although no association between PLF and infant growth was identified, we cannot ignore the potential harm posed by PLF. Future studies could assess infant size at an earlier time point, such as 1-month postpartum, or use longitudinal data to assess more subtle differences in growth trajectories with PLF.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03683667 and NCT02909179.

Determinants of nutritional status among under-five children receiving Integrated Child Development Services (ICDS) in India

Background: Undernutrition is a significant public health problem and the leading risk factor for India's disease burden. Aim: To understand the determinants of nutritional status among under-five children receiving Integrated Child Development Services (ICDS) in India. Methods: The study used the National Family Health Survey-4 (2015-16) data. The analysis was carried out for under-five children who have availed of any ICDS services in the 12 months preceding the survey (n = 1,27,813). Stunting, wasting, and underweight were estimated following the World Health Organization guideline and used as the outcome variables. The binary logistic regression was conducted to examine the association of ICDS utilization and socioeconomic-demographic predictors with under-five children's nutritional status. STATA (V 13) was used for statistical analyses. Results: A sizable proportion of under-five children receiving any ICDS services suffer from undernutrition. The undernutrition prevalence varied considerably by socioeconomic and demographic characteristics. Logistic regression found an insignificant association of ICDS utilization with the nutritional status of under-five children. Children not immunized in ICDS centers were less likely to be stunted (OR: 0.93; P < 0.01), wasted (OR: 0.93; P < 0.01), and underweight (OR: 0.90; P < 0.01) than their counterparts. The child's age and gender, maternal education and nutrition status, wealth index, social group, region, residence, and region were significant determinants of undernutrition among ICDS beneficiaries. Conclusion: The study suggests the need to ensure all available services to children enrolled in the Anganwadi Center (AWC). The program should also emphasize feeding practices and educate parents about improving child health and nutrition.

Age-appropriate feeding practices and their association with undernutrition among children aged 6-23 months in aspirational districts of India: a multinomial analysis

'Health and nutrition' is one among the five areas covered by the Aspirational District Programme in India, which aims to achieve the Sustainable Development Goals (SDGs). The reduction of undernutrition in under-five children has remained a major focus of the SDGs, especially at the ages of 6-23 months as this affects child development. This study used National Family Health Survey 2015-16 data to examine appropriate feeding practices and their associations with undernutrition among children aged 6-23 months in the 124 aspirational districts of India. Multinomial logistic regression analysis was used to analyse the association between feeding practices and undernutrition, adjusting for covariates. A total of 13,851 children aged 6-23 months were included in the analysis. Child nutritional outcomes, and children receiving the recommended minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD), were poorer in the aspirational compared with non-aspirational districts. However, the proportions of children who continued to breastfed, i.e. currently breastfeeding and the proportion of children who were receiving appropriate breastfeeding, i.e. receiving complementary feeding, in addition to breast milk, were higher in the aspirational districts. Appropriate breastfeeding and MDD were found to be associated negatively with undernutrition. While the continuation of breastfeeding increased the odds of children being undernourished, appropriate breastfeeding lowered the odds. The significant predictors of undernourishment among the study children were the child being male, of higher birth order, older and of smaller than average birth size; mother's lower educational level, mother's lower BMI of mothers and being a teenage mother; and poor household drinking water, sanitation facilities and lower economic status. This study suggests that educating mothers, especially illiterate and poor mothers, about appropriate breastfeeding and dietary diversity could help prevent and reduce child undernutrition in the aspirational districts of India.

Are stunted child - overweight mother pairs a real defined entity or a statistical artifact?

In a methodological contribution, Dieffenbach & Stein (DS) (The Journal of Nutrition, 142(4), 771-773.) concluded that the double burden of malnutrition (DBM), represented by stunted child - overweight mother pairs (SCOM), is a statistical artifact, meaning that SCOM does not describe a unique phenomenon because the observed rates of SCOM across a number of countries were not strongly different from the product of observed rates of maternal overweight (OM) and child stunting (SC), which DS referred to as the expected rate of SCOM. However, a growing literature continues to use SCOM as an indicator of the DBM. This study shows that the analysis by DS is not sufficient to conclude that SCOM can be explained by the co-occurrence of OM and SC due to chance alone because the analysis by DS was conducted at the country level, but applied to SCOM, which is a household-level variable. Using Demographic and Health Surveys data from 202 country-year data sets, we do not confirm important implicit assumptions that are required for the claim by DS to be supported. We also outline that comparing the expected to the observed rate of SCOM is primarily informative when putting it in relation to factors that influence the supply and demand of food consumed by households. When considering these factors, we find further evidence that it is misleading to consider SCOM as a statistical artifact, as the difference between the observed and the expected rate of SCOM significantly differs by household wealth. Recognizing that SCOM is a distinct phenomenon is important for policymakers who develop double-duty strategies that address malnutrition, and for researchers who need useful indicators to study the determinants of malnutrition at the household level.

What explains the large disparity in child stunting in the Philippines? A decomposition analysis

OBJECTIVE

About one-third of under-five Filipino children are stunted, with significant socio-economic inequality. This study aims to quantify factors that explain the large gap in stunting between poor and non-poor Filipino children.

DESIGN

Using the 2015 Philippine National Nutrition Survey, we conducted a linear probability model to examine the determinants of child stunting and then an Oaxaca-Blinder decomposition to explain the factors contributing to the gap in stunting between poor and non-poor children.

SETTING

Philippines.

PARTICIPANTS

1881 children aged 6-23 months participated in this study.

RESULTS

The overall stunting prevalence was 38·5 % with a significant gap between poor and non-poor (45·0 % v. 32·0 %). Maternal height, education and maternal nutrition status account for 26 %, 18 % and 17 % of stunting inequality, respectively. These are followed by quality of prenatal care (12 %), dietary diversity (12 %) and iron supplementation in children (5 %).

CONCLUSIONS

Maternal factors account for more than 50 % of the gap in child stunting in the Philippines. This signifies the critical role of maternal biological and socio-economic circumstances in improving the linear growth of children.

Prevalence of Undernutrition and Its Associated Factors Among Lactating Women in the Shebedino District, Sidama Regional State, Ethiopia

Background: Ensuring the nutritional status of lactating women is crucial to prevent maternal morbidity and mortality in poor countries like Ethiopia. Hence, this study aimed to assess the prevalence of undernutrition and its associated factors among lactating women in Shebedino district, Sidama Regional State, Ethiopia.

Methods: A community-based cross-sectional study was conducted among randomly selected 612 lactating women from February to March 2020. Data were collected by using an interviewer-administered, structured, and pretested questionnaire. Also, physical measurements (weight, height, and body mass index) were measured by using standardized and calibrated instruments. Data entered into Epi data version 3.1 and exported to SPSS version 23 for further analysis. Descriptive statistics, bivariable, and multivariable logistic regression analysis were done. A P-value of ≤.05 was used to consider the statistical significance.

Result: The prevalence of undernutrition was 25.9% (95% CI: 22.5, 29.5). Having polygamous husband (AOR = 3.47, 95% CI: 1.13, 10.68), belonged to households with less than 5 members (AOR = 1.81, 95% CI: 1.16, 2.83), abortion history in the last 6 months (AOR = 3.09, 95% CI: 1.73, 5.51), poor household wealth status (AOR = 3.85, 95% CI: 1.89, 7.81), and medium wealth status (AOR = 2.07, 95% CI: 1.06, 4.03) were factors positively associated with undernutrition.

Conclusion: Undernutrition among lactating women was high in the study area. Attention should be given to the economic status of the women, family planning services, abortion prevention, and habits of marrying more than 1 wife (polygamy).

Effectiveness of peer counseling and membership in breastfeeding support groups in promoting optimal breastfeeding behaviors in the Philippines

Background

The prevalence of early initiation of breastfeeding and exclusive breastfeeding (EBF) at 6 months remain low in the Philippines. To help meet the 90% early initiation of breastfeeding target and to improve infant and young child feeding practices in the Philippines, the Millennium Development Goals - Fund 2030 Joint Programme (JP) on Ensuring Food Security and Nutrition for Children 0–24 months old was implemented. We aimed to determine the effectiveness of visits by peer counselors during pregnancy and after delivery, and membership in breastfeeding support groups in promoting these optimal breastfeeding practices.

Methods

We used data from the Endline Survey of the JP to study the effects of prenatal and postnatal peer counselor visits, and membership in breastfeeding support groups, and their possible interactions with initiation of breastfeeding within 1 hour of birth among children aged 0 to 24 months and EBF at 6 months among children aged 6 to 24 months, while adjusting for confounding. We used logistic regression methods for survey data to assess these associations.

Results

Of the 2343 mother-infant pairs, only 1500 (63.1%) practiced early initiation of breastfeeding. Of the 1865 children aged 6 months or older, only 621 (34.7%) were exclusively breastfed at 6 months. After adjusting for confounding variables, there was no strong evidence that peer counselor visits were associated with early initiation or EBF at 6 months. However, members of breastfeeding support groups had 1.49 times higher odds of early initiation of breastfeeding (95% CI [Confidence Interval] 1.12, 1.98) and 1.65 times higher odds of EBF (95% CI 1.20, 2.24) compared to those who were not members of breastfeeding support groups. There was no interaction between the different exposure variables and early initiation and EBF at 6 months.

Conclusions

Our findings suggest breastfeeding support groups may be institutionalized to promote both early initiation of breastfeeding and EBF in the Philippines, while the role of peer counselors in promoting optimal breastfeeding behaviors should be further reviewed. Our suggestion to integrate non-healthcare professionals to promote early initiation of breastfeeding and EBF could be tested in future intervention studies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13006-021-00400-5.

Associations between dietary patterns and anaemia in 6- to 23-month-old infants in central South China

BACKGROUND

Anaemia is prevalent in children. Therefore, this study examined the association between dietary patterns and anaemia among children in central South China.

METHODS

Cross-sectional studies were conducted in Mayang, central South China, in 2015 and 2018. Diet data were collected using a questionnaire, and dietary patterns were identified via exploratory factor analysis. Haemoglobin was measured to assess anaemia status. Associations between dietary patterns and anaemia were assessed using a logistic regression model.

RESULTS

The mean age of the infants surveyed was 14.06 months in 2015 and 16.58 months in 2018. Four dietary patterns were identified among infants aged 6-23 months: a diversified diet consisting mainly of tubers, dairy products, beans and bean products; a traditional diet consisting mainly of cereals, water, soup, vegetables and fruit; mainly breast milk, with a little powdered formula; or mainly multi-nutrient powders. The prevalence of anaemia in infants decreased from 29.49% in 2015 to 20.26% in 2018.In infants fed a diversified diet or multi-nutrient powders with top-quartile (Q4) scores, the risk of anaemia was reduced by 45%(adjusted odds ratio [AOR] = 0.55, 95%CI0.30-0.99, P = 0.047) or 59% (AOR = 0.41, 95% CI0.22-0.78, P = 0.006), respectively, compared to infants in the lowest quartile (Q1). Infants fed mainly breast milk had a 3.26-fold greater risk of anaemia compared to those with Q1 scores (AOR = 3.26, 95% CI 1.83-5.81, P < 0.001).

CONCLUSIONS

Four dietary patterns were identified among infants aged 6-23 months in central South China. Infants should be fed a variety of food groups to improve their anaemia status.

Associations between the household environment and stunted child growth in rural India: a cross-sectional analysis

Stunting is a major unresolved and growing health issue for India. There is a need for a broader interdisciplinary cross-sectoral approach in which disciplines such as the environment and health have to work together to co-develop integrated socio-culturally tailored interventions. However, there remains scant evidence for the development and application of such integrated, multifactorial child health interventions across India's most rural communities. In this paper we explore and demonstrate the linkages between environmental factors and stunting thereby highlighting the scope for interdisciplinary research. We examine the associations between household environmental characteristics and stunting in children under 5 years of age across rural Rajasthan, India. We used Demographic and Health Survey (DHS)-3 India (2005-2006) data from 1194 children living across 109,041 interviewed households. Multiple logistic regression analyses independently examined the association between (i) the primary source of drinking water, (ii) primary type of sanitation facilities, (iii) primary cooking fuel type, and (iv) agricultural land ownership and stunting adjusting for child age. The results suggest, after adjusting for child age, household access to (i) improved drinking water source was associated with 23% decreased odds [odds ratio (OR) = 0.77, 95% confidence interval (CI) 0.5-1.00], (ii) improved sanitation facility was associated with 41% decreased odds (OR = 0.51, 95% CI 0.3-0.82), and (iii) agricultural land ownership was associated with 30% decreased odds of childhood stunting (OR 0.70, 95% CI 0.51-0.94]. The cooking fuel source was not associated with stunting. Our findings indicate that a shift is needed from nutrition-specific to contextually appropriate interdisciplinary solutions, which incorporate environmental improvements. This will not only improve living conditions in deprived communities but also help to tackle the challenge of childhood malnutrition across India's most vulnerable communities.

Complementary feeding patterns of Filipino infants and toddlers lack diversity, especially among children from poor households

Background

Consumption of nutritionally adequate complementary foods is essential for optimal growth and development of infants and toddlers, including those in developing countries. The aim of this study was to describe the food and beverage consumption patterns among 6-23.9 month old Filipino infants and toddlers, by household wealth.

Methods

Data from 1087 infants and toddlers from the 2013 National Nutrition Survey were included. Dietary intake data was assessed using a 24Hr recall and population food intakes were stratified into pre-defined wealth categories.

Results

Breast milk, infant formula, powdered milk and rice were the most commonly consumed foods and beverages across the age groups. Several differences in complementary feeding by wealth status were observed. Infants from poor households (69%) reported significantly greater consumption of human milk, than those from rich households (42%) who reported a significantly greater consumption of infant/toddler formula (Poor: 22%, Rich: 56%) (P < 0.05). A higher percentage of toddlers from rich households consumed protein-containing foods, cookies and cakes. There was a significant difference in vegetable consumption in 12-17.9 month old children (Poor: 17%, Rich: 31%; P = 0.021). Human milk and formula were the top contributors to energy in 6-17.9 month old children, while rice was the top energy contributor in 18-23.9 month old children.

Conclusion

Milk and rice were the main dietary components in all Filipino children, contributing up to 60% of energy in the infants from poorer households. Consumption of protein-containing foods and vegetables were typically lower in poorer households. Interventions are required to enable caregivers of young Filipino children to provide complementary foods of high nutritional quality, particularly among children from the poor households.

Feeding practices for toddlers with stunting in Jakarta: A case study

Stunting represents a child's failure to thrive. On the basis of the World Health Organization child growth standards, stunting is a height of <-2 SD of the z-score for the child's age. There are several major causes of stunting. One is the inability to optimize child feeding practices. The aim of this study was to explore the feeding practices that lead to stunting in toddlers in Jakarta. The participants in this study were 15 mothers. Content analysis was the method that was chosen for this study. The data analysis revealed four themes that describe the feeding practices for toddlers with stunting in Jakarta: i) mothers providing instant porridge and ready-to-serve steamed chicken rice; ii) a feeding frequency of small portions only 2-3 times per day; iii) a lack of diet diversity; and iv) the suboptimal intake of iron-rich foods. The provision of effective education about appropriate feeding practices to pregnant women and mothers with toddlers is expected to reduce the incidence of stunting in Indonesia.

Effect of Eel Biscuit Supplementation on Height of Children with Stunting Aged 36-60 Months: A Pilot Study

Background

Stunting is a major health problem in developing countries. Animal-based supplements can increase the height of children with stunting. This study was aimed at determining the effect of eel biscuit supplementation on increase in the height of children with stunting aged 36-60 months.

Methods

A pilot study with pretest-post-test design. The study was conducted in two villages in the Priangan Region, West Java Province, Indonesia. The participants were divided into two groups: intervention group (10 supplemented eel biscuit pieces) and control group (biscuits from the government's biscuit programme). A total of 56 children aged 36-60 months with the height-for-age z-score of <-2 SD were recruited voluntarily for sampling.

Results

The initial height-for-age z-score of the intervention group was -3.45 SD and that of the control group was -3.11 SD. After 3 months of supplemented eel biscuit consumption, the height-for-age z-score of the intervention group changed to -2.52 SD and that of the control group changed to -2.51 SD. The average shift of the height-for-age z-score after 3 months of supplemented eel biscuit consumption was 0.93 SD in the intervention group and 0.6 SD in the control group. There were significant differences in delta and percent increase in the height-for-age z-score between both groups.

Conclusions

Consumption of supplemented eel biscuits for 3 months increased the height-for-age z-score of children with stunting aged 36-60 months by 0.93 SD.

Stunting and severe stunting among infants in India: the role of delayed introduction of complementary foods and community and household factors

Background: Delayed introduction of solid, semi-solid or soft foods (complementary feeding) and associated factors are related to stunting and severe stunting among children in many low- and middle-income countries. In India, however, there is limited evidence on the relationship between delayed complementary feeding and associated factors with stunting and severe stunting to advocate for policy interventions.

Objectives: The present study investigated the relationship between delayed complementary feeding and associated factors with stunting and severe stunting among infants aged 6–8 months in India.

Methods: Survey data on 13,548 infants aged 6–8 months were obtained from the 2015–16 National Family Health Survey in India. Logistic regression (Generalized Linear Latent and Mixed Models [GLLAMM] with a logit link and binomial family) models that adjusted for clustering and sampling weights were used to investigate the relationship between delayed complementary feeding and associated factors (community, household, maternal, child and health service factors) with stunting and severe stunting among infants aged 6–8 months in India.

Results: The prevalence of stunting and severe stunting was 22.0% (95% CI: 21.0–23.7%) and 10.0% (95% CI: 9.0–11.0%) among infants aged 6–8 months who received no complementary foods, respectively. Delayed introduction of solid, semi-solid or soft foods was associated with stunting (adjusted Odd ratios [aOR] = 1.24, 95% CI: 1.09–1.41) and severe stunting (aOR = 1.21, 95% CI: 1.01–1.45) among infants aged 6–8 months. High maternal education (secondary or higher education) and household wealth (middle, richer and richest) were protective against stunting and severe stunting.

Conclusion: Delayed introduction of complementary foods and associated factors were related to stunting and severe stunting among infants aged 6–8 months in India. Reducing the proportion of infants who are stunted in India would require comprehensive national nutrition policy actions that target the sub-population of mothers with no schooling and limited resources.

On the characteristic and stability of iron diet supplements

The iron diet supplements: AproFER 1000 and AproTHEM were subjected to various chemical, microbial and magnetic analysis. The microbial analysis revealed no presence of pathogenic bacteria in the studied products. No significant changes in iron content or forms (bivalent/trivalent) were observed in EPR analysis of supplements stored at different conditions for a long period of time. The chemical and magnetic analysis showed that both AproFER 1000 and AproTHEM contain a high concentration of bivalent iron so they can be used as an iron diet supplements.

Micronutrient Deficiencies, Nutritional Status and the Determinants of Anemia in Children 0-59 Months of Age and Non-Pregnant Women of Reproductive Age in The Gambia

Data on micronutrient deficiency prevalence, nutrition status, and risk factors of anemia in The Gambia is scanty. To fill this data gap, a nationally representative cross-sectional survey was conducted on 1354 children (0-59 months), 1703 non-pregnant women (NPW; 15-49 years), and 158 pregnant women (PW). The survey assessed the prevalence of under and overnutrition, anemia, iron deficiency (ID), iron deficiency anemia (IDA), vitamin A deficiency (VAD), and urinary iodine concentration (UIC). Multivariate analysis was used to assess risk factors of anemia. Among children, prevalence of anemia, ID, IDA, and VAD was 50.4%, 59.0%, 38.2%, and 18.3%, respectively. Nearly 40% of anemia was attributable to ID. Prevalence of stunting, underweight, wasting, and small head circumference was 15.7%, 10.6%, 5.8%, and 7.4%, respectively. Among NPW, prevalence of anemia, ID, IDA and VAD was 50.9%, 41.4%, 28.0% and 1.8%, respectively. Anemia was significantly associated with ID and vitamin A insufficiency. Median UIC in NPW and PW was 143.1 µg/L and 113.5 ug/L, respectively. Overall, 18.3% of NPW were overweight, 11.1% obese, and 15.4% underweight. Anemia is mainly caused by ID and poses a severe public health problem. To tackle both anemia and ID, programs such as fortification or supplementation should be intensified.

Cruz PC, Borromeo TH, Lalusin A, Hernandez JE, Acuin C, Reinke R, Swamy BPM. Zinc and Iron Nutrition Status in the Philippines Population and Local Soils

The Philippines is one of the major rice-producing and rice-consuming countries of Asia. A large portion of its population depends on rice for their daily caloric intake and nutritional needs. The lack of dietary diversity among poor communities has led to nutritional consequences, particularly micronutrient deficiencies. Iron-deficiency anemia (IDA) and zinc deficiency (ZnD) are two serious nutritional problems that affect the health and economic sector of the country. Since rice dominates the Filipino diet by default, biofortification of rice will help improve the micronutrient status. The Philippine government has proactively initiated various programs and policies to address micronutrient deficiencies, particularly through fortification of basic food commodities. Biofortification, the fortification of rice with micronutrients through breeding, is considered the most sustainable and cost-effective strategy that can benefit large vulnerable populations. However, developing promising genotypes with micronutrient-enriched grains should be coupled with improving micronutrient bioavailability in the soil in order to optimize biofortification. This review documents the prevailing soil Zn-deficiency problems in the major rice production areas in the Philippines that may influence the Zn nutritional status of the population. The article also reports on the biofortification efforts that have resulted in the development of two biofortified varieties approved for commercial release in the Philippines. As nutritional security is increasingly recognized as a priority area, greater efforts are required to develop biofortified rice varieties that suit both farmers' and consumers' preferences, and that can address these critical needs for human health in a sustainable and cost-effective manner.

An Investigation of the Prevalence and Causes of Malnutrition in Iran: a Review Article and Meta-analysis

Malnutrition is one of the most important health issues in developing countries, which might have adverse effects on the physical and intellectual health of children. The search process was started to find Persian and English articles published until September 2017 regarding the prevalence of malnutrition in children under the age of six in Iran using national and international databases including SID, Magiran, Irandoc, IranMedex, PubMed, Medline, Scopus, and ISI Web of Science. The data were analyzed using meta-analysis methods and the random effects model. The heterogeneity of studies was analyzed using the I² index. The data were analyzed using R and STATA software (ver. 11.2). Twenty seven articles conducted from 2002 to 2016 were collected to be included in the meta-analysis process. The total sample size was 161,941 patients in an age range of 0-6 years. The final estimate of the prevalence of different forms of malnutrition through meta-analysis of data extracted from studies in Iran was as follows: severe underweight (1%; 95% confidence interval [CI], 1–1), moderate underweight (6%; 95% CI, 5–7), mild underweight (25%; 95% CI, 21–28), severe short stature (3%; 95% CI, 2–3), moderate short stature (8%; 95% CI, 6–9), mild short stature (21%; 95% CI, 17–24), severe slimness (1%; 95% CI, 1–1), moderate slimness (5%; 95% CI, 4–5) and mild slimness (20%; 95% CI, 17–24). Considering that the prevalence of malnutrition is relatively high in Iran, health authorities should plan to improve the nutritional status of children.

Nutrient Intakes and Food Sources of Filipino Infants, Toddlers and Young Children are Inadequate: Findings from the National Nutrition Survey 2013

Comprehensive assessment of nutrient intakes and food sources of nutrients in Filipino children under 5 years old are lacking. We studied energy and nutrient intakes and food sources in 4218 children aged 6⁻59.9 months using two 24-h dietary recalls. Usual energy and nutrient intakes were estimated using the PC-SIDE program. Reported foods and beverages were assigned to one of 85 food groups. Percentage contribution of each food group to nutrient intake was calculated. The results showed that the intake of total fat as a percentage of energy and of most micronutrients were highly inadequate. The prevalence of inadequate nutrient intakes, defined as the percent of children with intakes less than the estimated average requirements (EAR) ranged from 60⁻90% for iron, calcium, vitamin C, and zinc and ranged from 30⁻50% for others such as vitamin A, thiamine, riboflavin, niacin, vitamin B6, and phosphorus. The diets of these children were composed of limited foods, namely a large amount of refined rice and other low-nutrient-dense foods (cookies and sugar), while vegetables, fruits, meats, and eggs made little contribution to daily energy or nutrients. These findings provide direction to health professionals developing food-based recommendations and strategies to tackle the shortfalls in the diet of this population.

Epidemiology of anaemia in children, adolescent girls, and women in Bhutan

Anaemia inhibits health and development in Bhutan. We estimated anaemia prevalence and explored risk factors in children and women using data from Bhutan's National Nutrition Survey 2015. Prevalence was calculated using life-stage-specific cut-offs adjusted for altitude and survey design. Risk factors were evaluated in modified Poisson regressions. Anaemia affected 42%, 29%, 36%, and 28% of children, adolescent girls, and non-pregnant and pregnant women, respectively. Risk of anaemia was greater in children who were younger (RR 2.0, 95% CI [1.7, 2.3] and RR 1.9, 95% CI [1.6, 2.3], respectively, for 12-23 and 6-11 vs. 24-59 months), male (1.2, 1.1-1.4, ref.: female), and stunted (1.2, 1.0-1.3, ref.: height-for-age ≥ -2z). Older (15-19 years) versus younger (10-14 years) adolescents were at higher risk (1.5, 1.2-1.8), as were adolescents living at home versus at school (1.2, 0.9-1.6) and those working versus studying (1.3, 1.0-1.7). Among adult women, anaemia risk increased with age (1.2, 1.0-1.4 and 1.3, 1.1-1.5, for 30-39 and 40-49, respectively, vs. 20-29 years) and was higher for women without schooling (1.1, 1.0-1.3, vs. primary schooling), who were unmarried or separated (1.4, 1.2-1.7 and 1.3, 1.1-1.6, respectively, vs. married), without a child <5 years (1.1, 1.0-1.3), and lacking improved sanitation (1.1, 1.0-1.3). High coverage of antennal iron and folic acid supplementation may contribute to the lower prevalence of anaemia among pregnant women and women with young children. Expansion of iron supplementation programmes, fortification, and other strategies to improve dietary iron intake may reduce the prevalence of anaemia, but causes of anaemia other than iron deficiency (e.g., thalassemias) should also be investigated.

Effects of Inflammation on Biomarkers of Vitamin A Status among a Cohort of Bolivian Infants

Globally, vitamin A deficiency (VAD) affects nearly 200 million children with negative health consequences. VAD can be measured by a retinol-binding protein (RBP) and serum retinol concentrations. Their concentrations are not always present in a 1:1 molar ratio and are affected by inflammation. This study sought to quantify VAD and its impact on infant mortality and infectious morbidity during the first 18 months of life in a cohort of mother-infant dyads in El Alto, Bolivia, while accounting for the previously mentioned measurement issues. Healthy mother-infant dyads (n = 461) were enrolled from two hospitals and followed for 12 to 18 months. Three serum samples were collected (at one to two, six to eight, and 12 to 18 months of infant age) and analyzed for RBP, and a random 10% subsample was analyzed for retinol. Linear regression of RBP on retinol was used to generate RBP cut-offs equivalent to retinol <0.7 µmol/L. All measures of RBP and retinol were adjusted for inflammation, which was measured by a C-reactive protein and alpha (1)-acid glycoprotein serum concentrations using linear regression. Infant mortality and morbidity rates were calculated and compared by early VAD status at two months of age. Retinol and RBP were weakly affected by inflammation. This association varied with infant age. Estimated VAD (RBP < 0.7 µmol/L) decreased from 71.0% to 14.8% to 7.7% at two, six to eight, and 12 to 18 months of age. VAD was almost nonexistent in mothers. Early VAD was not significantly associated with infant mortality or morbidity rates. This study confirmed a relationship between inflammation and vitamin A biomarkers for some subsets of the population and suggested that the vitamin A status in early infancy improves with age and may not have significantly affected morbidity in this population of healthy infants.

The relationship between serum retinol concentrations and subclinical infection in rural Brazilian children

ABSTRACT Objective To evaluate the relationship between serum retinol concentrations and subclinical infection in children from rural settlements. Methods A cross-sectional population-based study was carried out in nine rural settlements in the northeastern region of Brazil, involving 118 children aged 6 to 59 months. The relationship between serum retinol and C-Reactive Protein levels, an important marker of infectious and inflammatory processes, was investigated by multiple linear regression, controlling for demographic, socioeconomic and nutritional variables. Serum retinol and C-Reactive Protein were measured, respectively, by High Performance Liquid Chromatography and immunoturbidimetric assay in automated equipment. Results Vitamin A deficiency (retinol <0.70μmol/L) was identified in 9.3% of the children. C-Reactive Protein was the only predictor of retinol concentrations in the final regression model, causing a 0.728μmol/L reduction in retinol concentrations in the studied children (p=0.008). Conclusion Vitamin A deficiency is a problem of mild/moderate severity and measures to control infectious diseases in this population are fundamental to prevent and/or combat this problem.

Prevalence and determinants of stunting in a conflict-ridden border region in Armenia - a cross-sectional study

BACKGROUND

Despite global efforts, stunting remains a public health problem in several developing countries. The prevalence of stunting among 0- to 5-year-old children in Armenia has increased from 17% in 2000 to 19% in 2010. A baseline study was conducted among preschool children in Berd, a region near the northeastern border of Armenia that has experienced intermittent military tension for over 20 years.

METHODS

We conducted a cross-sectional study including 594 children aged 6-month- 6 years old and their caregivers in our analysis, to assess the prevalence and determinants of stunting. We calculated the anthropometric measurements and hemoglobin levels of children; analyzed children's stool and conducted a survey with children's caregivers. We employed the hierarchical logistic regression model to explore the predictors of stunting among 25-72 months old children and multivariable logistic regression models to investigate the predictors of stunting among 6-24 months old children. Individual and residence level variables were included in the models including anemia, minimum dietary diversity, mothers' height, the overall duration of breastfeeding, birthweight, child's history of diarrhea and mean socio-economic score.

RESULTS

The prevalence of stunting was significantly higher among the 6-24 months old children (13.3%) compared to the children aged 25-72 months old (7.8%). We did not find any differences in the prevalence of stunting by place of residence in either age group. The 6-24 months old children who consumed at least four food groups during the previous day (minimum dietary diversity) had 72% lower odds of being stunted (p < 0.05). Each kilogram increase in birthweight was associated with 76% lower odds of being stunted (OR = 0.24, p < 0.01). Mother's height significantly decreased the odds of stunting among the children 25-72- months old (OR = 0.86, p < 0.001). BMI was also a significant predictor of stunting among both age-groups.

CONCLUSIONS

The study results highlight the significance of mother's height, birthweight, and adequate complementary feeding to reduce stunting. Further studies are needed to determine the possible association of anemia and stunting with the ongoing conflict in the region, as well as socioeconomic conditions and food insecurity in the region.

Methodologic approach for the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project

Background: The Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia (BRINDA) project is a multiagency and multicountry collaboration that was formed to improve micronutrient assessment and to better characterize anemia.Objectives: The aims of the project were to 1) identify factors associated with inflammation, 2) assess the relations between inflammation, malaria infection, and biomarkers of iron and vitamin A status and compare adjustment approaches, and 3) assess risk factors for anemia in preschool children (PSC) and women of reproductive age (WRA).Design: The BRINDA database inclusion criteria included surveys that 1) were conducted after 2004, 2) had target groups of PSC, WRA, or both, and 3) used a similar laboratory methodology for the measurement of ≥1 biomarker of iron [ferritin or soluble transferrin receptor or vitamin A status (retinol-binding protein or retinol)] and ≥1 biomarker of inflammation (α-1-acid glycoprotein or C-reactive protein). Individual data sets were standardized and merged into a BRINDA database comprising 16 nationally and regionally representative surveys from 14 countries. Collectively, the database covered all 6 WHO geographic regions and contained ∼30,000 PSC and 27,000 WRA. Data were analyzed individually and combined with the use of a meta-analysis.Results: The methods that were used to standardize the BRINDA database and the analytic approaches used to address the project's research questions are presented in this article. Three approaches to adjust micronutrient biomarker concentrations in the presence of inflammation and malaria infection are presented, along with an anemia conceptual framework that guided the BRINDA project's anemia analyses.Conclusions: The BRINDA project refines approaches to interpret iron and vitamin A biomarker values in settings of inflammation and malaria infection and suggests the use of a new regression approach as well as proposes an anemia framework to which real-world data can be applied. Findings can inform guidelines and strategies to prevent and control micronutrient deficiencies and anemia globally.

The Proportion of Anemia Associated with Iron Deficiency in Low, Medium, and High Human Development Index Countries: A Systematic Analysis of National Surveys

Iron deficiency is commonly assumed to cause half of all cases of anemias, with hereditary blood disorders and infections such as hookworm and malaria being the other major causes. In countries ranked as low, medium, and high by the Human Development Index, we conducted a systematic review of nationally representative surveys that reported the prevalence of iron deficiency, iron deficiency anemia, and anemia among pre-school children and non-pregnant women of reproductive age. Using random effects meta-analyses techniques, data from 23 countries for pre-school children and non-pregnant women of reproductive age was pooled, and the proportion of anemia attributable to iron deficiency was estimated by region, inflammation exposure, anemia prevalence, and urban/rural setting. For pre-school children and non-pregnant women of reproductive age, the proportion of anemia associated with iron deficiency was 25.0% (95% CI: 18.0, 32.0) and 37.0% (95% CI: 28.0, 46.0), respectively. The proportion of anemia associated with iron deficiency was lower in countries where anemia prevalence was >40%, especially in rural populations (14% for pre-school children; 16% for non-pregnant women of reproductive age), and in countries with very high inflammation exposure (20% for pre-school children; 25% for non-pregnant women of reproductive age). Despite large heterogeneity, our analyses suggest that the proportion of anemia associated with iron deficiency is lower than the previously assumed 50% in countries with low, medium, or high Human Development Index ranking. Anemia-reduction strategies and programs should be based on an analysis of country-specific data, as iron deficiency may not always be the key determinant of anemia.

The Proportion of Anemia Associated with Iron Deficiency in Low, Medium, and High Human Development Index Countries: A Systematic Analysis of National Surveys

Iron deficiency is commonly assumed to cause half of all cases of anemias, with hereditary blood disorders and infections such as hookworm and malaria being the other major causes. In countries ranked as low, medium, and high by the Human Development Index, we conducted a systematic review of nationally representative surveys that reported the prevalence of iron deficiency, iron deficiency anemia, and anemia among pre-school children and non-pregnant women of reproductive age. Using random effects meta-analyses techniques, data from 23 countries for pre-school children and non-pregnant women of reproductive age was pooled, and the proportion of anemia attributable to iron deficiency was estimated by region, inflammation exposure, anemia prevalence, and urban/rural setting. For pre-school children and non-pregnant women of reproductive age, the proportion of anemia associated with iron deficiency was 25.0% (95% CI: 18.0, 32.0) and 37.0% (95% CI: 28.0, 46.0), respectively. The proportion of anemia associated with iron deficiency was lower in countries where anemia prevalence was >40%, especially in rural populations (14% for pre-school children; 16% for non-pregnant women of reproductive age), and in countries with very high inflammation exposure (20% for pre-school children; 25% for non-pregnant women of reproductive age). Despite large heterogeneity, our analyses suggest that the proportion of anemia associated with iron deficiency is lower than the previously assumed 50% in countries with low, medium, or high Human Development Index ranking. Anemia-reduction strategies and programs should be based on an analysis of country-specific data, as iron deficiency may not always be the key determinant of anemia.

Anemia e deficiência de micronutrientes em lactentes atendidos em unidades básicas de saúde em Rio Branco, Acre, Brasil

Resumo O presente estudo investigou os fatores associados à anemia e deficiência de micronutrientes em análise transversal conduzida com 150 crianças de 11 a 14 meses atendidas em unidades básicas de saúde em Rio Branco, Acre. Amostras de sangue venoso foram obtidas para avaliar a ocorrência de anemia, deficiência de ferro (DF) e de vitaminas A (DVA) e B12 (DVB12). Modelos múltiplos de regressão de Poisson foram utilizados para identificar fatores associados à anemia. Anemia, DF, DVA e DVB12 foram observadas em 23%, 76%, 18% e 20% das crianças, respectivamente. Os fatores associados à anemia foram: não ser filho único, residir em domicílio sem acesso a TV a cabo ou internet, déficit de estatura para idade (E/I), introdução tardia da alimentação complementar superior a 240 dias, DVA, DVB12, e evidência de infecção vigente (proteína C reativa plasmática > 5 mg/L). Houve menor ocorrência de anemia entre crianças com peso ao nascer > 3.500g. Do total de crianças, 82% apresentaram pelo menos uma das deficiências de micronutrientes (DF, DVA, DVB12). Ações com ênfase em práticas alimentares saudáveis oportunas, melhor manejo de morbidades e suplementação com outros micronutrientes devem ser priorizadas no aprimoramento do serviço de puericultura da atenção básica à saúde deste município.

Vitamin A status and associated factors in infants attending at Primary Health Care in Goiânia, Goiás, Brazil

OBJECTIVE

This study aimed to assess the nutritional status of vitamin A and associated factors in children assisted in Primary Care Health in Goiânia, Goiás, Brazil.

METHODS

This is a cross-sectional study with a sample of 228 children 12 to 16 months of age. The nutritional status of vitamin A was assessed by serum retinol concentration, determined by high performance liquid chromatography. Multiple linear regression models with hierarchical selection of independent variables were used to evaluate the correlation with serum retinol as the dependent variable.

RESULTS

The vitamin A deficiency (retinol < 0,7 μmol/L) was observed in 14,0% of the children. Maternal schooling and hemoglobin concentration were positively correlated with serum retinol concentration, while C-reactive protein showed a negative correlation (R2 = 0,1648).

CONCLUSION

The vitamin A deficiency in one-year-old children attended in Basic Health Units in Goiânia configures itself as a moderate public health problem. Actions to promote maternal education, morbidity control and prevention of other micronutrient deficiencies are important for prevention and control of the vitamin A deficiency in this population.

Food Fortification for Addressing Iron Deficiency in Filipino Children: Benefits and Cost-Effectiveness

Iron deficiency is one of the most widespread nutritional disorders in both developing and industrialized countries, making it a global public health concern. Anemia, mainly due to iron deficiency, affects one third of the world's population and is concentrated in women and children below 5 years of age. Iron deficiency anemia has a profound impact on human health and productivity, and the effects of iron deficiency are especially pronounced in the first 1,000 days of life. This critical window of time sets the stage for an individual's future physiological and cognitive health, underscoring the importance of addressing iron deficiency in infants and young children. This review focuses on the use of fortified foods as a cost-effective tool for addressing iron deficiency in infants and young children in the Philippines.

G6PD Deficiency and Hemoglobinopathies: Molecular Epidemiological Characteristics and Healthy Effects on Malaria Endemic Bioko Island, Equatorial Guinea

Background

Glucose-6-phosphate dehydrogenase (G6PD) deficiency and hemoglobinopathies were the inherited conditions found mostly in African. However, few epidemiological data of these disorders was reported in Equatorial Guinea (EQG). This study aimed to assess the prevalence and healthy effects of G6PD deficiency and hemoglobinopathies among the people on malaria endemic Bioko Island, EQG.

Materials and Methods

Blood samples from 4,144 unrelated subjects were analyzed for G6PD deficieny by fluorescence spot test (FST), high-resolution melting assay and PCR-DNA sequencing. In addition, 1,186 samples were randomly selected from the 4,144 subjects for detection of hemoglobin S (HbS), HbC, and α-thalassemia deletion by complete blood count, PCR-DNA sequencing and reverse dot blot (RDB).

Results

The prevalence of malaria and anemia was 12.6% (522/4,144) and 32.8% (389/1,186), respectively. Overall, 8.7% subjects (359/4,144) were G6PD-deficient by FST, including 9.0% (249/2,758) males and 7.9% (110/1,386) females. Among the 359 G6PD-deficient individuals molecularly studied, the G6PD A^- (G202A/A376G) were detected in 356 cases (99.2%), G6PD Betica (T968C/A376G) in 3 cases. Among the 1,186 subjects, 201 cases were HbS heterozygotes, 35 cases were HbC heterozygotes, and 2 cases were HbCS double heterozygotes; 452 cases showed heterozygous α-thalassemia 3.7 kb deletion (-α^3.7 kb deletion) and 85 homozygous - α^3.7 kb deletion. The overall allele frequencies were HbS 17.1% (203/1186); HbC, 3.1% (37/1186); and –α^3.7 kb deletion 52.4% (622/1186), respectively.

Conclusions

High G6PD deficiency in this population indicate that diagnosis and management of G6PD deficiency is necessary on Bioko Island. Obligatory newborn screening, prenatal screening and counseling for these genetic disorders, especially HbS, are needed on the island.

Iron metabolism in obesity: how interaction between homoeostatic mechanisms can interfere with their original purpose. Part I: underlying homoeostatic mechanisms of energy storage and iron metabolisms and their interaction

Adipose tissue plasticity mediated by inflammation is an important evolutionary achievement to survive seasonal climate changes. It permits to store excessive calories and to release them if required, using inflammatory cells to remove the debris. This process is regulated by a complex interaction of cytokines (TNF-α, IL-6), adipokines (adiponectin, apelin, liptin), adhesion molecules (ICAM-1, VCAM-1, E-selectin) and transcription factors (NF-κB, HIF-1α). Iron mediates electron transfer as an essential component of e.g. myeloperoxidase, hemoglobin, cytochrome C and ribonucleotide reductase. Conversely, unbound iron can catalyze oxidation of lipids, proteins, and DNA. To balance the essential with the potentially toxic function requires an efficient iron homoeostasis. This is mediated by hepcidin's interaction with the iron-exporter ferroportin, to adapt intestinal iron absorption and body iron-sequestration to changes in demand. In addition, the interaction of iron-responsive elements (IRE) and iron-responsive proteins (IRP), the IRE/IRP-mechanism, regulates cellular iron homoeostasis. Obesity-induced inflammation interacts with both these mechanisms and disturbs iron availability by impairing its absorption, and by sequestering it in the reticuloendothelial system. Both mechanisms lead to anemia and reduce physical fitness which, in a vicious cycle, can support the development of pathological obesity. Thus, interaction between these two sets of beneficial regulatory mechanisms can become detrimental in situations of ample calorie supply.