Infant malnutrition is associated with persisting attention deficits in middle adulthood

A New Murine Undernutrition Model Based on Complementary Feeding of Undernourished Children Causes Damage to the Morphofunctional Intestinal Epithelium Barrier

BACKGROUND

Complementary feeding is critical in establishing undernutrition. However, experimental undernourished diets do not represent the amount of nutrients in the complementary diets of undernourished children.

OBJECTIVES

To develop, validate, and evaluate the impact of a new murine model of undernutrition on the intestinal epithelium, based on the complementary diet of undernourished children from 7 countries with low-socioeconomic power belonging to the Malnutrition-Enteric Diseases (MAL-ED) cohort study.

METHODS

We used the difference in the percentage of energy, macronutrients, fiber and zinc in the complementary diet of children without undernutrition compared with stunting (height-for-age Z-score < -2) for the MAL-ED diet formulation. Subsequently, C57BL/6 mice were fed a control diet (AIN-93M diet) or MAL-ED diet for 28 d. Weight was measured daily; body composition was measured every 7 d; lactulose:mannitol ratio (LM) and morphometry were evaluated on days 7 and 28; the cotransport test and analysis of intestinal transporters and tight junctions were performed on day 7.

RESULTS

The MAL-ED diet presented -8.03% energy, -37.46% protein, -24.20% lipid, -10.83% zinc, +5.93% carbohydrate, and +45.17% fiber compared with the control diet. This diet rapidly reduced weight gain and compromised body growth and energy reserves during the chronic period (P < 0.05). In the intestinal epithelial barrier, this diet caused an increase in the LM (P < 0.001) and reduced (P < 0.001) the villous area associated with an increase in FAT/CD36 in the acute period and increased (P < 0.001) mannitol excretion in the chronic period.

CONCLUSIONS

The MAL-ED diet induced undernutrition in mice, resulting in acute damage to the integrity of the intestinal epithelial barrier and a subsequent increase in the intestinal area during the chronic period. This study introduces the first murine model of undernutrition for the complementary feeding phase, based on data from undernourished children in 7 different countries.

Early childhood malnutrition impairs adult resting brain function using near-infrared spectroscopy

Introduction

Early childhood malnutrition affects 200+ million children under 5 years of age worldwide and is associated with persistent cognitive, behavioral and psychiatric impairments in adulthood. However, very few studies have investigated the long-term effects of childhood protein-energy malnutrition (PEM) on brain function using a functional hemodynamic brain imaging technique.

Objective and methods

This study aims to investigate functional brain network alterations using near infrared spectroscopy (NIRS) in adults, aged 45-51 years, from the Barbados Nutrition Study (BNS) who suffered from a single episode of malnutrition restricted to their first year of life (n = 26) and controls (n = 29). A total of 55 individuals from the BNS cohort underwent NIRS recording at rest.

Results and discussion

Using functional connectivity and permutation analysis, we found patterns of increased Pearson's correlation with a specific vulnerability of the frontal cortex in the PEM group (ps < 0.05). Using a graph theoretical approach, mixed ANCOVAs showed increased segregation (ps = 0.0303 and 0.0441) and decreased integration (p = 0.0498) in previously malnourished participants compared to healthy controls. These results can be interpreted as a compensatory mechanism to preserve cognitive functions, that could also be related to premature or pathological brain aging. To our knowledge, this study is the first NIRS neuroimaging study revealing brain function alterations in middle adulthood following early childhood malnutrition limited to the first year of life.

Is there evidence of a causal link between childhood maltreatment and attention deficit/hyperactivity disorder? A systematic review of prospective longitudinal studies using the Bradford-Hill criteria

Background

Studies report an elevated risk of maltreatment in children with attention deficit/hyperactivity disorder (ADHD), and elevated levels of ADHD in people who suffered childhood maltreatment (CM). However, the direction(s) of causality between CM and ADHD remain unclear-does ADHD create a context for CM, does CM cause ADHD, or both?

Objective

This study systematically reviews and qualitatively synthesizes the research evidence relating to this question using Bradford-Hill criteria for establishing causality-strength, temporality, dose-response and plausibility.

Methods

We conducted a systematic review, following PRISMA guidelines, of prospective longitudinal studies examining both CM and ADHD. We then used Bradford-Hill criteria to assess the quality of evidence for a causal link between CM and ADHD.

Results

All 11 included studies demonstrated an association between CM and ADHD. Seven included evidence for temporality: five suggesting that CM precedes ADHD in the lifespan; two suggesting ADHD precedes CM. Four studies demonstrated a dose response relationship in which greater CM exposure was associated with elevated risk of ADHD. Studies presented a range of plausible mechanisms, including CM causing ADHD through biological programming, versus ADHD causing CM through parental stress.

Conclusions

The high quality prospective longitudinal studies reviewed confirm the association between ADHD and CM, but present conflicting evidence about the direction of causality and mechanisms underpinning this association. To better understand the complex interplay between CM and ADHD, more studies using new research designs will be required that can partition effects by type of CM and account for bidirectional effects and other complexities.

Consumption of a multi-deficient diet causes dynamic changes in the intestinal morphofunctional barrier, body composition and impaired physical development in post-weaning mice

Few studies have focused on nutrient-deficient diets and associated pathobiological dynamics of body composition and intestinal barrier function. This study evaluated the impact of a nutrient-deficient diet on physical development and intestinal morphofunctional barrier in mice. C57BL/6 (21 days of age) mice were fed a Northeastern Brazil regional basic diet (RBD) or a control diet for 21 d. The animals were subjected to bioimpedance analysis, lactulose test, morphometric analysis and quantitative reverse transcription-PCR to evaluate tight junctions and intestinal transporters. RBD feeding significantly reduced weight (P < 0·05) from day 5, weight gain from day 3 and tail length from day 14. The intake of RBD reduced total body water, extracellular fluid, fat mass and fat-free mass from day 7 (P < 0·05). RBD induced changes in the jejunum, with an increase in the villus:crypt ratio on day 7, followed by reduction on days 14 and 21 (P < 0·05). Lactulose:mannitol ratio increased on day 14 (P < 0·05). Changes in intestinal barrier function on day 14 were associated with reductions in claudin-1 and occludin, and on day 21, there was a reduction in the levels of claudin-2 and occludin. SGLT-1 levels decreased on day 21. RBD compromises body composition and physical development with dynamic changes in intestinal barrier morphofunctional. RBD is associated with damage to intestinal permeability, reduced levels of claudin-1 and occludin transcripts and return of bowel function in a chronic period.

Association between Hyperemesis Gravidarum in pregnancy on postnatal ability of infants to attend to a play task with their mother

Research indicates a higher prevalence of attention deficits in children exposed to HG in utero compared to controls with some claiming that the deficit is due to prenatal effects of malnutrition in HG mothers and others that it is due to maternal mental health after birth. The current study examines the effect of hyperemesis gravidarum (HG) diagnosis during pregnancy on infant attention controlling for maternal stress, depression anxiety and attachment. Thirty-eight infants mean age 4 months were videotaped with their mothers (19 mothers with a hyperemesis diagnosis and 19 controls) during play with a soft toy and looking at a picture book. Infant attention was operationalized as gaze direction towards the play activity, mother, and 'distracted' (indicated by looking away from play or mother). Mothers completed stress, depression, anxiety, and attachment questionnaires. HG exposed infants attended for significantly less time during play with a book or soft toy compared to controls. Maternal stress, depression, anxiety, and attachment did not differ in HG mothers and controls. Infant ability to attend to the toy, book, mother or being distracted did not relate to maternal postnatal attachment, or mental health. These results suggest that the prenatal environment, especially exposure to HG might be associated with reduced infant attention abilities independent of maternal postnatal health.

9-Demethoxy-medicarpin: A potential bone health supplement for the management of protein deficiency-induced bone loss in growing rats

Human skeleton requires an adequate supply of many different nutritional factors for optimal growth and development. The role of nutrition in bone growth has piqued interest in recent years, especially in relation to maximizing peak bone mass and reducing the risk of osteoporosis. Protein deficiency-induced bone loss was induced in female growing rats. All experimental rodent diets were prepared as per recommendations for growing animals. 9-Demethoxy-medicarpin (DMM) treatment was given to growing Sprague Dawley (SD) rats at 1 mg and 10 mg dose orally for 30 days. Bones were collected for bone mineral density (BMD). Bone marrow cells were isolated from femur for calcium nodule formation. Serum samples were collected for biochemical parameters. We found that DMM treatment speeds up the recovery of musculoskeletal weakness by replenishing nutrients in proven rodent model. DMM supplementation for four weeks showed significantly increased vertebral, femur and tibial BMD compared with the untreated PD group. Albumin levels were significantly enhanced in treatment groups, in which 10 mg dose imparted a better effect. We conclude that DMM treatment led to increased BMD and biochemical parameters in protein deficient condition in growing rats and has potential as a bone growth supplement.

‘Mens sana in corpore Sano’: Home food consumption implications over child cognitive performance in vulnerable contexts

Diet directly affects children’s physical and mental development. Nonetheless, how food insecurity and household food consumption impact the cognitive performance of children at risk of social exclusion remains poorly understood. In this regard, children in Guatemala face various hazards, mainly related to the socioeconomic difficulties that thousands of families have in the country. The main objective of this study was to analyze the differences in cognitive performance considering food insecurity and household food consumption in a sample of rural and urban Guatemalan children and adolescents at risk of social exclusion. Child cognitive performance was assessed in 134 children and adolescents (age M = 11.37; SD = 3.54) from rural and urban settings. Language, attention, and executive functions were assessed using neuropsychological tasks. Differences in cognitive performance in each level of food insecurity and household diet consumption were compared using the Mann–Whitney U test. A stepwise multivariate regression analysis was conducted to determine which factors may influence cognitive scores. The results showed that rural and urban groups did not differ in terms of food insecurity. However, considering just rural areas, differences were found between groups with food security and insecurity in attention and executive function tasks. Moreover, differences were found in food consumption for certain groups of food (e.g., meat, U = 1,146, p < 0.001, g = 0.72). Regarding regressions, protein food consumption (e.g., meat and fish), which is related to having a more balanced diet, was a relevant factor in executive performance. Contrary to what we expected, performance in attentional tasks was not related to the consumption of any food group. These findings could help politicians and decision-makers to select actions focused on improving diet balance and food security in families at risk of social exclusion. It is necessary to carry out more specific studies on the factors related to diet that affect the cognitive development of minors at risk of social exclusion. In addition, it is necessary to study the implementation of alternative interventions that include low-cost nutrients, thus ensuring that minors have access to a more balanced diet.

Protocol for a randomised placebo-controlled trial investigating the efficacy and safety of a vitamin-mineral formula targeting dysregulated emotions in teenagers: The balancing emotions of adolescents with micronutrients (BEAM) study

Background

Emotional dysregulation (ED) is a significant contributing factor to psychological distress in young people. ED is a transdiagnostic dimension characterized by an excessive reactivity to negative emotional stimuli with affective (anger) and behavioral (aggression) components, and is present across anxiety, mood and behavioral disorders. Due to early onset, high prevalence and persistence, ED in childhood is one of the most psychosocially impairing and cost-intensive mental health conditions, with not enough children improving with conventional treatments. Clinical trials have established preliminary efficacy of micronutrients (vitamins and minerals) in the treatment of ED. This project expands the research to examine micronutrient efficacy for teenagers with ED.

Methods

This study is the first double-blind (participant and investigators) 8 week randomized controlled trial (with 8 week open-label extension and one year follow-up) designed to explore the efficacy and safety of micronutrients compared with placebo in 150 medication-free emotionally dysregulated youth (12–17 years), referred via self-referral, delivered remotely throughout New Zealand, using a website for monitoring symptoms, with a psychologist available online via text, email and video for assessment and monitoring. The primary outcome measures will be the Clinical Global Impression (CGI-I), the reactivity subscale of the Emotion Dysregulation Inventory (EDI) and the Clinician Rated Temper and Irritability Scale (CL-ARI).

Discussion

Micronutrient intervention delivered alongside online assessment and monitoring has the potential to transform delivery of mental health care to young people who may not be willing or able to access traditional therapies. We also hope that this intervention shows acceptability across different ethnicities.

Edible insects prevent changes to brain monoamine profiles from malnourishment in weaned rats

Background: Childhood malnutrition can have devastating consequences on health, behavior, and cognition. Edible insects are sustainable low cost high protein and iron nutritious foods that can prevent malnutrition. However, it is unclear whether insect-based diets may help prevent changes to brain neurochemistry associated with malnutrition.Materials and Methods: Weanling male Sprague-Dawley rats were malnourished by feeding a low protein-iron diet (LPI, 5% protein and ∼2 ppm Fe) for 3 weeks or nourished by feeding a sufficient protein-iron diet (SPI, 15% protein 20 ppm FeSO₄) for the duration of the study. Following 3 weeks of LPI diet, three subsets of the malnourished rats were placed on repletion diets supplemented with cricket, palm weevil larvae, or the SPI diet for 2 weeks, while the remaining rats continued the LPI diet for an additional 2 weeks. Monoamine-related neurochemicals (e.g. serotonin (5-HT), dopamine (DA), norepinephrine) and select monoamine metabolites were measured in the hypothalamus, hippocampus, striatum, and prefrontal cortex using Ultra High-Performance Liquid Chromatography.Results: Five weeks of LPI diets disrupted brain monoamines, most notable in the hypothalamus. Two weeks supplementation with cricket and palm weevil larvae diets prevented changes to measures of 5-HT and DA turnover in the hippocampus and hypothalamus. Moreover, these insect diets prevented the malnutrition-induced imbalance of 5-HT and DA metabolites in the hippocampus, striatum, and hypothalamus.Conclusion: Edible insects such as cricket and palm weevil larvae could be sustainable nutrition intervention to prevent behavioral and cognitive impairment associated abnormal brain monoamine activities that results from early life malnutrition.

Impact of Early Childhood Malnutrition on Adult Brain Function: An Evoked-Related Potentials Study

More than 200 million children under the age of 5 years are affected by malnutrition worldwide according to the World Health Organization. The Barbados Nutrition Study (BNS) is a 55-year longitudinal study on a Barbadian cohort with histories of moderate to severe protein-energy malnutrition (PEM) limited to the first year of life and a healthy comparison group. Using quantitative electroencephalography (EEG), differences in brain function during childhood (lower alpha1 activity and higher theta, alpha2 and beta activity) have previously been highlighted between participants who suffered from early PEM and controls. In order to determine whether similar differences persisted into adulthood, our current study used recordings obtained during a Go-No-Go task in a subsample of the original BNS cohort [population size (N) = 53] at ages 45–51 years. We found that previously malnourished adults [sample size (n) = 24] had a higher rate of omission errors on the task relative to controls (n = 29). Evoked-Related Potentials (ERP) were significantly different in participants with histories of early PEM, who presented with lower N2 amplitudes. These findings are typically associated with impaired conflict monitoring and/or attention deficits and may therefore be linked to the attentional and executive function deficits that have been previously reported in this cohort in childhood and again in middle adulthood.

Neurodevelopmental, cognitive, behavioural and mental health impairments following childhood malnutrition: a systematic review

BACKGROUND

Severe childhood malnutrition impairs growth and development short-term, but current understanding of long-term outcomes is limited. We aimed to identify studies assessing neurodevelopmental, cognitive, behavioural and mental health outcomes following childhood malnutrition.

METHODS

We systematically searched MEDLINE, EMBASE, Global Health and PsycINFO for studies assessing these outcomes in those exposed to childhood malnutrition in low-income and middle-income settings. We included studies assessing undernutrition measured by low mid-upper arm circumference, weight-for-height, weight-for-age or nutritional oedema. We used guidelines for synthesis of results without meta-analysis to analyse three outcome areas: neurodevelopment, cognition/academic achievement, behaviour/mental health.

RESULTS

We identified 30 studies, including some long-term cohorts reporting outcomes through to adulthood. There is strong evidence that malnutrition in childhood negatively impacts neurodevelopment based on high-quality studies using validated neurodevelopmental assessment tools. There is also strong evidence that malnutrition impairs academic achievement with agreement across seven studies investigating this outcome. Eight of 11 studies showed an association between childhood malnutrition and impaired cognition. This moderate evidence is limited by some studies failing to measure important confounders such as socioeconomic status. Five of 7 studies found a difference in behavioural assessment scores in those exposed to childhood malnutrition compared with controls but this moderate evidence is similarly limited by unmeasured confounders. Mental health impacts were difficult to ascertain due to few studies with mixed results.

CONCLUSIONS

Childhood malnutrition is associated with impaired neurodevelopment, academic achievement, cognition and behavioural problems but evidence regarding possible mental health impacts is inconclusive. Future research should explore the interplay of childhood and later-life adversities on these outcomes. While evidence on improving nutritional and clinical therapies to reduce long-term risks is also needed, preventing and eliminating child malnutrition is likely to be the best way of preventing long-term neurocognitive harms.

PROSPERO REGISTRATION NUMBER

CRD42021260498.

Early protein energy malnutrition impacts life-long developmental trajectories of the sources of EEG rhythmic activity

Protein Energy Malnutrition (PEM) has lifelong consequences on brain development and cognitive function. We studied the lifelong developmental trajectories of resting-state EEG source activity in 66 individuals with histories of Protein Energy Malnutrition (PEM) limited to the first year of life and in 83 matched classmate controls (CON) who are all participants of the 49 years longitudinal Barbados Nutrition Study (BNS). qEEGt source z-spectra measured deviation from normative values of EEG rhythmic activity sources at 5-11 years of age and 40 years later at 45-51 years of age. The PEM group showed qEEGt abnormalities in childhood, including a developmental delay in alpha rhythm maturation and an insufficient decrease in beta activity. These profiles may be correlated with accelerated cognitive decline.

Protein-energy Supplementation in Early-life Decreases the Odds of Mental Distress in Later Adulthood in Guatemala

BACKGROUND

Prevalence of mental health concerns is growing worldwide, along with lack of access to and receipt of needed treatment. Current gaps in treatment provision have led to exploring alternative methods of prevention, with research linking nutrition and mental health, of particular relevance in low- and middle- income countries with high prevalence of undernutrition.

OBJECTIVES

To examine whether exposure to a protein-energy nutritional supplement during the first 1000 days of life decreased odds of mental distress in adulthood among men and women in Guatemala compared to receiving a low energy-no protein supplement or supplementation outside the 1000-day window.

METHODS

Data from participants (n = 1249) in a longitudinal cohort protein-energy supplementation trial (early life, supplementation data from 1969-77, ages 0-7 years; life course, outcome data from 2017-2018 follow-up, ages 40-57 years) were analyzed for associations between nutrition in the first 1000 days and mental distress in adulthood (SRQ-20), controlling for early life variables and current life stress; life course variables (e.g., education) were examined as potential mediators of this relationship. Generalized linear mixed models and zero-inflated Poisson generalized linear mixed models were utilized.

RESULTS

Both partial and full supplementation with Atole during the first 1000 days were associated with 63% (95% CI: 0.16, 0.87) and 56% (95% CI: 0.19, 1.03) lower odds, respectively, of experiencing mental distress in adulthood. Results did not differ by sex. These inverse relationships remained relatively unchanged (partial OR = 0.34 [95% CI: 0.14, 0.83]; full OR = 0.38 [95% CI: 0.16, 0.92]) after controlling for early life and life course variables, including life stress.

CONCLUSIONS

Protein-energy supplementation during the first 1000 days of life in Guatemala where undernutrition is prevalent may reduce prevalence of later mental distress in adulthood. This effect appears to occur directly, rather than indirectly through pathways of life course variables such as education, wealth, and marital status.

Childhood ADHD, Going Beyond the Brain: A Meta-Analysis on Peripheral Physiological Markers of the Heart and the Gut

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common neurodevelopmental disorder diagnosed in children. Questions regarding its increased diagnostic rates and pharmacological treatments in developing children have led to a more holistic review of the multi-system pathophysiology observed in ADHD. The dopaminergic neurotransmitter system, known for its influence on reward-motivated behaviors and motor control, and the frontostriatal systems, that mediate motor, cognition, and behavior, are associated with ADHD's development. However, studies have shown that these neural systems do not wholly account for ADHD's multilayered and heterogeneous symptom presentation. For instance, the literature suggests that emotional dysregulation, the inability to regulate one's emotional responses to provoking stimuli, is associated with increased risk for social impairment in ADHD. A broader examination of physiological systems in children with ADHD has found potential markers in the heart-brain and gut-brain axes that correspond with certain behaviors associated with emotional dysregulation in recent studies. Hence, the purpose of this meta-analysis is to aggregate ten applicable published case studies and analyze task-related heart rate reactivity (HRR; n = 5 studies) and gut microbiota (n = 5 studies) data in children with and without ADHD. Data from a total of 531 youth with ADHD and 603 youth without ADHD revealed significant small and medium effect sizes for higher Chao1 levels and Actinobacteria levels in the ADHD group, respectively, but no evidence of altered task-related HRR. Thus, further research into multi-system psychophysiological measures of emotional dysregulation and ADHD is warranted. The clinical, empirical, and educational implications of these findings are discussed.

SYSTEMATIC REVIEW REGISTRATION

https://www.crd.york.ac.uk/prospero/, identifier PROSPERO (CRD42021236819).

Malnutrition and the microbiome as modifiers of early neurodevelopment

Malnutrition refers to a dearth, excess, or altered differential ratios of calories, macronutrients, or micronutrients. Malnutrition, particularly during early life, is a pressing global health and socioeconomic burden that is increasingly associated with neurodevelopmental impairments. Understanding how perinatal malnutrition influences brain development is crucial to uncovering fundamental mechanisms for establishing behavioral neurocircuits, with the potential to inform public policy and clinical interventions for neurodevelopmental conditions. Recent studies reveal that the gut microbiome can mediate dietary effects on host physiology and that the microbiome modulates the development and function of the nervous system. This review discusses evidence that perinatal malnutrition alters brain development and examines the maternal and neonatal microbiome as a potential contributing factor.

Effectiveness of Ready-to-Use Therapeutic Food in Improving the Developmental Potential and Weight of Children Aged under Five with Severe Acute Malnourishment in Pakistan: A Pretest-Posttest Study

The objective of this study was to assess whether the standard therapy of ready-to-use therapeutic food in the treatment of uncomplicated severe acute malnutrition (SAM) is effective in improving developmental potential and weight gain in children aged under five years. A multicenter pretest-posttest study was conducted among 91 children aged under five with uncomplicated SAM in Pakistan. Study participants completed their eight weeks’ therapy of ready-to-use therapeutic food according to the World Health Organization’s (WHO) standard guidelines. The study outcome was the proportion of children with improved developmental potential in all domains in comparison with the pretreatment status and children gaining >15% of their baseline weight; mean weight-for-height/length z-score after completing eight weeks’ therapy of ready-to-use therapeutic food. The Denver Development Screening Tool II was used for developmental screening. Significant changes (p < 0.05) were observed for developmental status milestones in terms of gross motor, fine motor, and personal/social milestones, as well as language and global development milestones. There was a strong positive correlation (r = 0.961) between initial weight and weight at the last visit (p < 0.001). Ready-to-use therapeutic food is effective in improving development potential as well as promoting weight gain in children aged under five with uncomplicated SAM if provided according to WHO guidelines.

Metabolomic changes in severe acute malnutrition suggest hepatic oxidative stress: a secondary analysis

Severe acute malnutrition (SAM), due to poor energy and/or protein intake, is associated with poor growth, depressed immune function, and long-term impacts on metabolic function. As the liver is a major metabolic organ and malnutrition poses metabolic stress, we hypothesize that SAM will be associated with alterations in the hepatic metabolome reflective of oxidative stress, gluconeogenesis, and ketogenesis. Thus, the purpose of this secondary analysis was to understand how SAM alters hepatic metabolism using a piglet model. Weanling piglets were feed either a reference (REF) or protein-energy deficient diet (MAL) for 5 weeks. After dietary treatment MAL piglets were severely underweight (weight-for-age Z-score of -3.29, Welch's t test, P = .0007), moderately wasted (weight-for-length Z-score of-2.49, Welch's t test, P = .003), and tended toward higher hepatic triglyceride content (Welch's t test, P = .07). Hematologic and blood biochemical measurements were assessed at baseline and after dietary treatment. The hepatic metabolome was investigated using ¹H-NMR spectroscopy. Hepatic concentrations of betaine, cysteine, and glutathione tended to be lower in MAL (Welch's t test with FDR correction, P < .1), while inosine, lactate, and methionine sulfoxide concentrations were higher in MAL (inosine: P = .0448, lactate: P = .0258, methionine sulfoxide: P = .0337). These changes suggest that SAM is associated with elevated hepatic oxidative stress, increased gluconeogenesis, and alterations in 1-carbon metabolism.

Food insecurity and brain health in adults: A systematic review

Food insecurity has been associated with adverse effects on physical health and well-being in both high and low-income countries, but effects on brain health are not clear. The purpose of this systematic review was to determine the relationship between food insecurity and important brain health outcomes in adults including depression, stroke, cognitive impairment and dementia. Electronic databases were searched to find studies which investigated relations between food insecurity and predefined brain health outcomes. Thirty studies met the inclusion criteria for review of which 23 were conducted in high income countries and seven in low- or middle-income countries. Most studies (n = 24) were cross-sectional, five were prospective and 1 was a case-control design. Seven studies reporting outcomes relating to cognitive performance and 24 relating to depression. No studies investigated relations between food insecurity and stroke or dementia. There was substantial heterogeneity in the populations studied as well as measures of food insecurity and outcomes which made comparisons between studies difficult. Overall, the findings highlighted that individuals who were food insecure had increased likelihood of depressive symptoms and poorer global cognition than those who were food secure. It is possible that social support and food aid programmes attenuate the effects of food insecurity on depressive symptoms. Future research is needed to determine whether interventions to alleviate food insecurity can benefit brain health in vulnerable populations.

Neurodevelopmental effects of childhood malnutrition: A neuroimaging perspective

Approximately one in five children worldwide suffers from childhood malnutrition and its complications, including increased susceptibility to inflammation and infectious diseases. Due to improved early interventions, most of these children now survive early malnutrition, even in low-resource settings (LRS). However, many continue to exhibit neurodevelopmental deficits, including low IQ, poor school performance, and behavioral problems over their lifetimes. Most studies have relied on neuropsychological tests, school performance, and mental health and behavioral measures. Few studies, in contrast, have assessed brain structure and function, and to date, these have mainly relied on low-cost techniques, including electroencephalography (EEG) and evoked potentials (ERP). The use of more advanced methods of neuroimaging, including magnetic resonance imaging (MRI) and functional near-infrared spectroscopy (fNIRS), has been limited by cost factors and lack of availability of these technologies in developing countries, where malnutrition is nearly ubiquitous. This report summarizes the current state of knowledge and evidence gaps regarding childhood malnutrition and the study of its impact on neurodevelopment. It may help to inform the development of new strategies to improve the identification, classification, and treatment of neurodevelopmental disabilities in underserved populations at the highest risk for childhood malnutrition.

The neural basis of attentional alterations in prenatally protein malnourished rats

Protein malnutrition during gestation alters brain development and produces specific behavioral and cognitive changes that persist into adulthood and increase the risks of neuropsychiatric disorders. Given evidence for the role of the prefrontal cortex in such diseases, it is significant that studies in humans and animal models have shown that prenatal protein malnutrition specifically affects functions associated with prefrontal cortex. However, the neural basis underlying these changes is unclear. In the current study, prenatally malnourished and control rats performed a sustained attention task with an unpredictable distractor, a task that depends on intact prefrontal cortical function. Radiolabeled 2-deoxyglucose was used to measure neural and brain network activity during the task. Results confirmed that adult prenatally malnourished rats were more distractible than controls and exhibited lower functional activity in prefrontal cortices. Thus, prefrontal activity was a predictor of task performance in controls but not prenatally malnourished animals. Instead, prenatally malnourished animals relied on different brain networks involving limbic structures such as the hippocampus. These results provide evidence that protein reduction during brain development has more wide-reaching effects on brain networks than previously appreciated, resulting in the formation of brain networks that may reflect compensatory responses in prenatally malnourished brains.

The enduring effect of prenatal protein malnutrition on brain anatomy, physiology and behavior

There is increasing evidence that the maternal environment exerts enduring influences on the fetal brain. In response to certain environmental stimuli such as reduced protein content, the fetus changes the course of its brain development, which leads to specific and programed changes in brain anatomy and physiology. These alterations produce a brain with a fundamentally altered organization, which then translates to alterations in adult cognitive function. The effects on brain and behavior may be linked, such that a prenatal stimulus relays a signal to alter brain development and encourage the selection and development of brain circuits and behaviors that would be beneficial for the environment in which the animal was anticipated to emerge. At the same time, the signal would deselect behaviors unlikely to be adaptive. We draw on evidence from rodent models to suggest that the brain that develops after a reduction in protein during the prenatal phase is not uniformly dysfunctional, but simply different. This perspective has implications for the role of prenatal factors in the production and expression of behavior, and may account for the elevation of risk factors for neurological and psychiatric illnesses.

Examining the Effect of Geographic Region of Residence on Childhood Malnutrition in Uganda

OBJECTIVES

In our study, we examine how geographic region of residence may predict childhood malnutrition, expressed as stunting, wasting and underweight, among children under the age of 5 years in Uganda.

METHODS

Using data from the 2016 Uganda Demographic and Health Survey, we performed an incremental multivariate multilevel mixed-effect modelling to examine the effect of a child, parental and household factors on the association between region of residence and each indicator of childhood malnutrition.

RESULTS

Approximately 28%, 3% and 9% of children under age 5 suffered from stunting, wasting and underweight, respectively. The bivariate result shows that the proportion of children suffering from stunting and underweight was relatively lower in the Kampala region compared with the other regions. With the exception of the Northern region (6.44%), wasting was higher (4.12%) among children in the Kampala region. Children in the other regions were more likely to experience stunting and underweight. When controlling for child, parent and household factors, children in the other regions were less likely to suffer from underweight and stunting, compared with those in Kampala region. Children in the other regions, except the Northern region, were less likely to be wasted compared with those in Kampala region.

CONCLUSION

Our finding suggests that child, parental and household characteristics have effects on the association between region of residence and childhood malnutrition. Addressing individual and household socioeconomic disparities may be vital in tackling regional differences in childhood malnutrition.

Redefining ADHD Using an Adult Population: Should Inattention be Viewed as a Separate Dimension From Cognitive and Physiological Activity Level?

Objective: The purpose of this study was to reexamine the latent structure of ADHD and sluggish cognitive tempo (SCT) due to issues with construct validity. Two proposed changes to the construct include viewing hyperactivity and sluggishness (hypoactivity) as a single continuum of activity level, and viewing inattention as a separate dimension from activity level. Method: Data were collected from 1,398 adults using Amazon's MTurk. A new scale measuring activity level was developed, and scores of Inattention were regressed onto scores of Activity Level using curvilinear regression. Results: The Activity Level scale showed acceptable levels of internal consistency, normality, and unimodality. Curvilinear regression indicates that a quadratic (curvilinear) model accurately explains a small but significant portion of the variance in levels of inattention. Conclusion: Hyperactivity and hypoactivity may be viewed as a continuum, rather than separate disorders. Inattention may have a U-shaped relationship with activity level. Linear analyses may be insufficient and inaccurate for studying ADHD.

Intergenerational effects of childhood maltreatment and malnutrition on personality maladaptivity in a Barbadian longitudinal cohort

Childhood adversities are linked with mental health problems throughout the life course, including personality pathology. Less is known about consequences in the next generation, particularly in non-Western populations. In the Barbados Nutrition Study, we assessed associations of two parental (G1) childhood adversities- (1) maltreatment history using the Childhood Trauma Questionnaire-Short Form (CTQ-SF), and (2) clinically ascertained infant malnutrition limited to the first year of life-on PD symptoms in their G2 offspring, using NEO FFM PD prototypes. In linear regression models clustered by family and adjusted for other G1 childhood adversities and family socioeconomic status, we found that G1 parental history of childhood maltreatment was significantly associated with increased G2 offspring Borderline, Histrionic, Narcissistic, and Dependent PD scores. When G1 childhood malnutrition was the exposure of interest, we found a significant association with Schizoid PD scores. When the sample was restricted to offspring of G1 mothers, even more extensive associations with G2 personality pathology were observed. This study supports a link between parental exposure to childhood adversities and increased personality maladaptivity in the next generation, with some specific patterns worthy of further exploration.

Food Insecurity and Cognitive Function in Middle to Older Adulthood: A Systematic Review

Food insecurity (FI) may limit cognitive functioning during aging. The goal of this systematic review was to summarize existing evidence linking FI and general or specific cognitive functions in middle and older adulthood. A systematic search of human studies published between 1 January 2000 and 30 April 2018 was conducted in PubMed, PsycINFO, and CAB Direct. Four independent reviewers assessed the eligibility of identified articles and conducted data extraction and data quality assessment. Ten studies were included in the review, including 1 cluster-randomized controlled trial, 2 longitudinal studies, and 7 cross-sectional studies. Three studies reported the association between early-life FI experience and a global cognitive function measure. Nine studies reported later-life FI experience in relation to global or specific cognitive functions. The results suggest an adverse association between FI experienced in early or later life and global cognitive function; and between later-life FI and executive function and memory. Findings from the review are preliminary because of sparse data, heterogeneity across study populations, exposure and outcome assessments, and potential risk of bias across studies. Future studies are recommended to better understand the role of FI in cognitive function, with the goal of identifying possible critical windows for correction of FI in vulnerable subpopulations to prevent neurocognitive deficit in adulthood.

The Forgotten Agenda of Wasting in Southeast Asia: Burden, Determinants and Overlap with Stunting: A Review of Nationally Representative Cross-Sectional Demographic and Health Surveys in Six Countries

Childhood wasting is among the most prevalent forms of undernutrition globally. The Southeast Asia region is home to many wasted children, but wasting is not recognized as a public health problem and its epidemiology is yet to be fully examined. This analysis aimed to determine the burden of wasting, its predictors, and the level of wasting and stunting concurrence. Datasets from Demographic and Health Surveys and Multiple Indicator Cluster Surveys in six countries in the region were analyzed. The pooled weighted prevalence for wasting and concurrent wasting and stunting among children 0–59 months in the six countries was 8.9%, 95% CI (8.0–9.9) and 1.6%, 95% CI (1.5–1.8), respectively. This prevalence is approximately 12-fold higher than the 0.7% prevalence of high-income countries; and translated into an absolute number of 1,088,747 children affected by wasting and 272,563 concurrent wasting and stunting. Wasting prevalence was 50 percent higher in the 0–23-month age group. Predictors for wasting included source of drinking water, wealth index, urban residence, child’s age and history of illness and mother’s body mass index. In conclusion, our analysis showed that wasting is a serious public health problem in the region that should be addressed urgently using both preventive and curative approaches.

Early development in children with moderate acute malnutrition: A cross-sectional study in Burkina Faso

Malnutrition impairs cognitive, communication, and motor development, but it is not known how nutrition and health are associated with development in children with moderate acute malnutrition (MAM). We aimed to describe motor and language development of children with MAM and explore its nutrition and health-related correlates. This cross-sectional study used baseline data from a nutritional trial in children with MAM aged 6-23 months in Burkina Faso. Motor and language skills were assessed using the Malawi Development Assessment Tool (MDAT). Linear mixed models were used to explore potential correlates of MDAT including socio-economic status, anthropometry, body composition, whole-blood polyunsaturated fatty acids (PUFA), haemoglobin (Hb), iron status, and morbidity. We also assessed child and caregiver participation during MDAT procedures and their associations with correlates and development. MDAT data were available for 1.608 children. Mean (95% CI) MDAT z-scores were -0.39 (-0.45, -0.34) for gross motor, 0.54 (0.48, 0.59) for fine motor, and -0.91 (-0.96, -0.86) for language skills. Children with higher mid-upper arm circumference, weight-for-height, height-for-age, fat-free mass, n-3 PUFAs, Hb, and iron status had better MDAT z-scores, whereas children with more fat mass index, anaemia, illness, and inflammation had poorer z-scores. In addition, children living in larger households or with an unmarried mother had poorer MDAT z-scores. Associations between morbidity and z-scores were largely explained by children's poorer participation during MDAT assessment. The identified factors associated with child development may inform interventions needed to stimulate development during or after management of MAM.

Rationale and design of an international randomized placebo-controlled trial of a 36-ingredient micronutrient supplement for children with ADHD and irritable mood: The Micronutrients for ADHD in Youth (MADDY) study

Background

Attention-Deficit/Hyperactivity Disorder (ADHD) is a chronic neurodevelopmental disorder affecting up to 9% of children and substantial numbers of adults. Existing pharmacologic treatments often improve symptoms, but concerns exist over side effects, stigma, potential long-term health effects, and residual irritability, often treated with adjunctive antipsychotics. To address public and clinician demand for non-pharmacologic evidence-based treatments, this study will examine efficacy of a 36-ingredient micronutrient (vitamin/mineral) supplement as treatment for children with ADHD and irritability.

Methods

An international team of experts in ADHD, mood dysregulation, nutrition, epidemiology, and clinical trials conferred to develop/refine a protocol powered to detect a medium effect. The study will employ a fully-blind randomized controlled trial (RCT) design, comparing the micronutrient supplement to matched placebo in 135 children aged 6-12 with ADHD symptoms and irritability, based on the parent-rated Child and Adolescent Symptom Inventory-5 (CASI-5). Irritability will be measured by at least one symptom of oppositional defiant disorder (ODD) or disruptive mood dysregulation disorder (DMDD). Based on research suggesting an irritable ADHD subtype, the primary outcome will be a composite score comprised of the CASI-5 subscales: ADHD, ODD, DMDD, and the Peer Conflict Scale, which assesses anger and aggression perpetrated towards peers. Participants will provide biological samples (blood, urine, saliva, hair and stool) to explore the micronutrients' mechanisms of action.

Discussion

This study is the first adequately powered RCT in North America to examine both behavioral responses to, and biological mechanisms of, micronutrients for ADHD and irritability in children. If found efficacious, broad-spectrum micronutrients, given at therapeutic doses, may provide an evidence-based alternative to prescription medications for ADHD and associated irritability.

Trial registration

NCT03252522. Registered 26 July 2017.

Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit

BACKGROUND

Global food insecurity persists despite continued international attention, necessitating evidence-based food assistance interventions that adequately address nutritional concerns. In June 2018, the US Agency for International Development's Office of Food for Peace through the Food Aid Quality Review (FAQR) project sponsored a "Food Assistance for Nutrition Evidence Summit" to share evidence relevant to policy and programmatic decision-making and to identify critical evidence gaps.

OBJECTIVE

This article presents 4 priority areas to advance nutrition in the international food assistance agenda generated through presentations and discussions with the food assistance community at the Evidence Summit.

METHODS

Priority areas were identified after the Evidence Summit using a combination of FAQR team discussions, review of presentations and official notes, and supporting literature.

RESULTS

Key priority areas to advance nutrition in the international food assistance agenda are as follows: (1) increase research funding for food assistance in all contexts, paying particular attention to emergency settings; (2) research and adopt innovative ingredients, technology, and delivery strategies in food assistance products and programs that encourage long-term well-being; (3) redefine and expand indicators of nutritional status to capture contextual information about the outcomes of food assistance interventions; and (4) augment communication and collaboration across the food assistance ecosystem.

CONCLUSIONS

These priorities are critical in a time of increased humanitarian need and will be key to fostering long-term resilience among vulnerable groups.

Human gut microbiome changes during a 10 week Randomised Control Trial for micronutrient supplementation in children with attention deficit hyperactivity disorder

It has been widely hypothesized that both diet and the microbiome play a role in the regulation of attention-deficit/hyperactivity disorder (ADHD) behaviour. However, there has been very limited scientific investigation into the potential biological connection. We performed a 10-week pilot study investigating the effects of a broad spectrum micronutrient administration on faecal microbiome content, using 16S rRNA gene sequencing. The study consisted of 17 children (seven in the placebo and ten in the treatment group) between the ages of seven and 12 years, who were diagnosed with ADHD. We found that micronutrient treatment did not drive large-scale changes in composition or structure of the microbiome. However, observed OTUs significantly increased in the treatment group, and showed no mean change in the placebo group. The differential abundance and relative frequency of Actinobacteria significantly decreased post- micronutrient treatment, and this was largely attributed to species from the genus Bifidobacterium. This was compensated by an increase in the relative frequency of species from the genus Collinsella. Further research is required to establish the role that Bifidobacterium contribute towards neuropsychiatric disorders; however, these findings suggest that micronutrient administration could be used as a safe, therapeutic method to modulate Bifidobacterium abundance, which could have potential implications for modulating and regulating ADHD behaviour. Our pilot study provides an initial observation into this area of research, and highlights an interesting avenue for further investigation in a larger cohort. Furthermore, these novel results provide a basis for future research on the biological connection between ADHD, diet and the microbiome.

High-dose vitamin D3 in the treatment of severe acute malnutrition: a multicenter double-blind randomized controlled trial

Background

Vitamin D deficiency is common in children with severe acute malnutrition, in whom it is associated with severe wasting. Ready-to-use therapeutic food (the standard treatment) contains modest amounts of vitamin D that do not reliably correct deficiency.

Objective

The aim of this study was to determine whether high-dose oral vitamin D3 enhances weight gain and development in children with uncomplicated severe acute malnutrition.

Design

We conducted a randomized placebo-controlled trial of high-dose vitamin D3 supplementation in children aged 6-58 mo with uncomplicated severe acute malnutrition in Pakistan. Participants were randomly assigned to receive 2 oral doses of 200,000 IU vitamin D3 or placebo at 2 and 4 wk after starting ready-to-use therapeutic food. The primary outcome was the proportion of participants gaining >15% of baseline weight at 8 wk after starting ready-to-use therapeutic food (the end of the study). Secondary outcomes were mean weight-for-height or -length z score and the proportion of participants with delayed development at the end of the study (assessed with the Denver Development Screening Tool II), adjusted for baseline values.

Results

Of the 194 randomly assigned children who started the study, 185 completed the follow-up and were included in the analysis (93 assigned to intervention, 92 to control). High-dose vitamin D3 did not influence the proportion of children gaining >15% of baseline weight at the end of the study (RR: 1.04; 95% CI: 0.94,1.15, P = 0.47), but it did increase the weight-for-height or -length z score (adjusted mean difference: 1.07; 95% CI: 0.49,1.65, P < 0.001) and reduce the proportion of participants with delayed global development [adjusted RR (aRR): 0.49; 95% CI: 0.31, 0.77, P = 0.002], delayed gross motor development (aRR: 0.29; 95% CI: 0.13, 0.64, P = 0.002), delayed fine motor development (aRR: 0.59; 95% CI: 0.38, 0.91, P = 0.018), and delayed language development (aRR: 0.57; 95% CI: 0.34, 0.96, P = 0.036).

Conclusions

High-dose vitamin D3 improved the mean weight-for-height or -length z score and developmental indexes in children receiving standard therapy for uncomplicated severe acute malnutrition in Pakistan. This trial was registered at clinicaltrials.gov as NCT03170479.

Prenatal Protein Malnutrition Leads to Hemispheric Differences in the Extracellular Concentrations of Norepinephrine, Dopamine and Serotonin in the Medial Prefrontal Cortex of Adult Rats

Exposure to prenatal protein malnutrition (PPM) leads to a reprogramming of the brain, altering executive functions involving the prefrontal cortex (PFC). In this study we used in vivo microdialysis to assess the effects of PPM on extracellular concentrations of norepinephrine (NE), dopamine (DA) and serotonin (5-HT) bilaterally in the ventral portion of the medial prefrontal cortex (vmPFC; ventral prelimbic and infralimbic cortices) of adult Long-Evans rats. Female Long-Evans rats were fed either a low protein (6%) or adequate protein diet (25%) prior to mating and throughout pregnancy. At birth, all litters were culled and fostered to dams fed a 25% (adequate) protein diet. At 120 days of age, 2 mm microdialysis probes were placed into left and right vmPFC. Basal extracellular concentrations of NE, DA, and 5-HT were determined over a 1-h period using HPLC. In rats exposed to PPM there was a decrease in extracellular concentrations of NE and DA in the right vmPFC and an increase in the extracellular concentration of 5-HT in the left vmPFC compared to controls (prenatally malnourished: N = 10, well-nourished: N = 20). Assessment of the cerebral laterality of extracellular neurotransmitters in the vmPFC showed that prenatally malnourished animals had a significant shift in laterality from the right to the left hemisphere for NE and DA but not for serotonin. In a related study, these animals showed cognitive inflexibility in an attentional task. In animals in the current study, NE levels in the right vmPFC of well-nourished animals correlated positively with performance in an attention task, while 5-HT in the left vmPFC of well-nourished rats correlated negatively with performance. These data, in addition to previously published studies, suggest a long-term reprogramming of the vmPFC in rats exposed to PPM which may contribute to attention deficits observed in adult animals exposed to PPM.

Prenatal Protein Malnutrition Produces Resistance to Distraction Similar to Noradrenergic Deafferentation of the Prelimbic Cortex in a Sustained Attention Task

Exposure to malnutrition early in development increases likelihood of neuropsychiatric disorders, affective processing disorders, and attentional problems later in life. Many of these impairments are hypothesized to arise from impaired development of the prefrontal cortex. The current experiments examine the impact of prenatal malnutrition on the noradrenergic and cholinergic axons in the prefrontal cortex to determine if these changes contribute to the attentional deficits seen in prenatal protein malnourished rats (6% casein vs. 25% casein). Because prenatally malnourished animals had significant decreases in noradrenergic fibers in the prelimbic cortex with spared innervation in the anterior cingulate cortex and showed no changes in acetylcholine innervation of the prefrontal cortex, we compared deficits produced by malnutrition to those produced in adult rats by noradrenergic lesions of the prelimbic cortex. All animals were able to perform the baseline sustained attention task accurately. However, with the addition of visual distractors to the sustained attention task, animals that were prenatally malnourished and those that were noradrenergically lesioned showed cognitive rigidity, i.e., were less distractible than control animals. All groups showed similar changes in behavior when exposed to withholding reinforcement, suggesting specific attentional impairments rather than global difficulties in understanding response rules, bottom-up perceptual problems, or cognitive impairments secondary to dysfunction in sensitivity to reinforcement contingencies. These data suggest that prenatal protein malnutrition leads to deficits in noradrenergic innervation of the prelimbic cortex associated with cognitive rigidity.

Early undernutrition as a cause of changes in phonological processing skills

ABSTRACT Purpose: to determine whether undernutrition in the first years of life affects the phonological awareness skills, the phonological working memory and the school performance of children. Methods: the participants were children with a history of moderate/severe undernutrition during their first years of life (G1) who achieved nutritional recovery (n = 15). The performance of G1 in different cognitive tasks (phonological awareness at the syllable and phoneme level, phonological working memory - repetition of digits and pseudowords, and reading, writing and arithmetic activities) was compared to that of children with school difficulties (G2) (n = 15) and without school difficulties (G3) (n = 15), all eutrophic ones. Results: the performance of G1 was worse than that of the other two groups in all tasks evaluated (mean score of G1, G2 and G3 and p-values: phonological awareness: 31, 41, 57 - 0.01; repetition of direct order digits: 18, 23, 28 - 0.001; writing: 4, 10, 22 - 0.001; reading: 26, 45, 65-0.001; arithmetic: 4, 7, 11- 0.001). Conclusion: the results demonstrate that undernutrition affected the cognitive development, causing changes in important cognitive skills for the development of written language.

Gut microbial features can predict host phenotype response to protein deficiency

Malnutrition remains a major health problem in low- and middle-income countries. During low protein intake, <0.67 g/kg/day, there is a loss of nitrogen (N2 ) balance, due to the unavailability of amino acid for metabolism and unbalanced protein catabolism results. However, there are individuals, who consume the same low protein intake, and preserve N2 balance for unknown reasons. A novel factor, the gut microbiota, may account for these N2 balance differences. To investigate this, we correlated gut microbial profiles with the growth of four murine strains (C57Bl6/J, CD-1, FVB, and NIH-Swiss) on protein deficient (PD) diet. Results show that a PD diet exerts a strain-dependent impact on growth and N2 balance as determined through analysis of urinary urea, ammonia and creatinine excretion. Bacterial alpha diversity was significantly (P < 0.05, FDR) lower across all strains on a PD diet compared to normal chow (NC). Multi-group analyses of the composition of microbiomes (ANCOM) revealed significantly differential microbial signatures between the four strains independent of diet. However, mice on a PD diet demonstrated differential enrichment of bacterial genera including, Allobaculum (C57Bl6/J), Parabacteroides (CD-1), Turicibacter (FVB), and Mucispirillum (NIH-Swiss) relative to NC. For instance, selective comparison of the CD-1 (gained weight) and C57Bl6/J (did not gain weight) strains on PD diet also demonstrated significant pathway enrichment of dihydroorodate dehydrogenase, rRNA methyltransferases, and RNA splicing ligase in the CD-1 strains compared to C57Bl6/J strains; which might account in their ability to retain growth despite a protein deficient diet. Taken together, these results suggest a potential relationship between the specific gut microbiota, N2 balance and animal response to malnutrition.

Childhood malnutrition and maltreatment are linked with personality disorder symptoms in adulthood: Results from a Barbados lifespan cohort

Both childhood malnutrition and maltreatment are associated with mental health problems that can persist into adulthood. Previously we reported that in Barbados, those with a history of infant malnutrition were more likely to report having experienced childhood maltreatment. Few studies, however, address the long-term outcomes of those who have been exposed to both. We assessed the unique and combined associations of a history of early malnutrition and childhood maltreatment with personality pathology in mid-adulthood in participants of the 47-year longitudinal Barbados Nutrition Study. We used the Structured Clinical Interview for DSM-IV-TR Axis II Personality Disorders Personality Questionnaire (SCID-II-PQ) and NEO Personality Inventory-Revised derived Five-Factor Model (NEO PI-R FFM) personality disorder (PD) scores to assess personality pathology, the Childhood Trauma Questionnaire-Short Form (CTQ-SF) to assess childhood maltreatment, and clinical documentation of malnutrition in infancy. We tested the associations of malnutrition and maltreatment with PD scores using linear regression models, unadjusted and adjusted for other childhood adversities. We found increased scores for paranoid, schizoid, avoidant, and dependent PDs among those who had been malnourished and increased scores for paranoid, schizoid, schizotypal, and avoidant PDs among those with higher childhood maltreatment scores. Overall, those exposed to both adversities had even greater PD scores.

Parental history of moderate to severe infantile malnutrition is associated with cognitive deficits in their adult offspring

OBJECTIVES

We compared the IQ and academic achievement of the young adult offspring of parents malnourished in infancy and those of a healthy control group in order to test the hypothesis that the offspring of previously malnourished individuals would show IQ and academic deficits that could be related to reduced parental socioeconomic status.

METHODS

We conducted a group comparison study based on a community sample in Barbados (Barbados Nutrition Study). Participants were adult children ≥16 years of age whose parents had been malnourished during the first year of life (n = 64; Mean age 19.3 years; 42% male) or whose parents were healthy community controls (n = 50; Mean age 19.7 years; 48% male). The primary outcome was estimated IQ (Wechsler Abbreviated Scale of Intelligence); a secondary outcome was academic achievement (Wide Range Achievement Test - Third Edition). Data were analyzed using PROC MIXED with and without adjusting for parental socioeconomic status (Hollingshead Index of Social Position).

RESULTS

IQ was reduced in the offspring of previously malnourished parents relative to the offspring of controls (9.8 point deficit; P < 0.01), but this difference was not explained by parental socioeconomic status or parental IQ. The magnitude of the group difference was smaller for basic academic skills and did not meet criteria for statistical significance.

DISCUSSION

The deleterious impact of infant malnutrition on cognitive function may be transmitted to the next generation; however, this intergenerational effect does not appear to be explained by the reduced socioeconomic status or IQ of the parent generation.

Evaluation of dietary intake in children and college students with and without attention-deficit/hyperactivity disorder

Objectives: To evaluate dietary intake among individuals with and without attention-deficit hyperactivity disorder (ADHD), to evaluate the likelihood that those with ADHD have inadequate intakes. Methods: Children, 7-12 years old, with (n = 23) and without (n = 22) ADHD, and college students, 18-25 years old, with (n = 21) and without (n = 30) ADHD comprised the samples. Children's dietary intake was assessed by a registered dietitian using 24-hour recalls over 3 days. College students kept a detailed food record over three days. Dietary information for both groups was entered into the Nutrition Data Systems for Research database, and output was analyzed using SAS 9.4. Nutrient analyses included the Healthy Eating Index-2010, Micronutrient Index (as a measure of overall micronutrient intake), and individual amino acids necessary for neurotransmission. Logistic regression was used to model the association of nutrient intake with ADHD. Models were adjusted for age, sex, IQ (or GPA), and energy intake (or total protein intake) as appropriate. Significance was evaluated at P = 0.05, and using the Benjamini-Hochberg corrected P-value for multiple comparisons. Results: No evidence existed for reduced nutrient intake among those with ADHD compared to controls in either age group. Across both groups, inadequate intakes of vitamin D and potassium were reported in 95% of participants. Children largely met nutrient intake guidelines, while college students failed to meet these guidelines for nine nutrients. In regards to amino acid intake in children, an increased likelihood of having ADHD was associated with higher consumption of aspartate, OR = 12.61 (P = 0.01) and glycine OR = 11.60 (P = 0.05); and a reduced likelihood of ADHD with higher intakes of glutamate, OR = 0.34 (P = 0.03). Among young adults, none of the amino acids were significantly associated with ADHD, though glycine and tryptophan approached significance. Discussion: Results fail to support the hypothesis that ADHD is driven solely by dietary micronutrient inadequacy. However, amino acids associated with neurotransmission, specifically those affecting glutamatergic neurotransmission, differed by ADHD status in children. Amino acids did not reliably vary among college students. Future larger scale studies are needed to further examine whether or not dietary intake of amino acids may be a modulating factor in ADHD.

Use of tuberculin skin test for assessment of immune recovery among previously malnourished children in Ethiopia

OBJECTIVE

To compare levels of immunity in children recovering from severe acute malnutrition (cases) against those of community controls (controls).

RESULTS

At baseline children recovering from severe acute malnutrition had lower, mid upper arm circumference (122 mm for cases and 135 mm for controls; p < 0.001), weight-for-height Z-score (- 1.0 for cases and - 0.5 for controls; p < 0.001), weight-for-age Z-score (- 2.8 for cases and - 1.1 for controls; p < 0.001) and height/length-for-age Z-score (- 3.6 for cases and - 1.4 for controls; p < 0.001), than controls. Age and gender matched community controls. At baseline, prevalence of a positive tuberculin skin test, assessed by cutaneous delayed-type hypersensitivity reaction skin test, was very low in both cases (3/93 = 3.2%) and controls (2/94 = 2.1%) and did not significantly increase at 6 months follow up (6/86 = 7.0% in cases and 3/84 = 3.4% in controls). The incidences of common childhood morbidities, namely fever, diarrhoea and cough, were 1.7-1.8 times higher among cases than controls. In conclusion, these results show that tuberculin skin test does not enable any conclusive statements regarding the immune status of patients following treatment for severe acute malnutrition. The increased incidence of infection in cases compared to controls suggests persistence of lower resistance to infection even after anthropometric recovery is achieved.

The structural relationship between early nutrition, cognitive skills and non-cognitive skills in four developing countries

This study provides evidence about how cognitive and non-cognitive skills are acquired during childhood in four developing countries (Ethiopia, India, Peru and Vietnam), highlighting the role of early nutrition as a determinant in this process. An increase of one standard deviation in height-for-age at the age of 1 is found to have a total effect on cognitive skills at age 8 by 5.4 percent in Ethiopia, 9.0 percent in India, 7.6 percent in Peru and 8.4 percent in Vietnam. The corresponding total effect on non-cognitive skills is 1.1 percent in Ethiopia, 3.4 percent in India, 2.6 percent in Peru and 1.7 percent in Vietnam. The evidence suggests the effect of early nutrition on non-cognitive skills is indirect, mediated by cognitive skills. The effect is also relatively small in magnitude.

Evaluation of a Nutritional Support Intervention in Malnourished HIV-Infected Children in Bamako, Mali

BACKGROUND

We assessed a nutritional support intervention in malnourished HIV-infected children in a HIV-care program of the University Hospital Gabriel Touré, Bamako, Mali.

METHODS

All HIV-infected children younger than 15 years were diagnosed for malnutrition between 07 and 12, 2014. Malnutrition was defined according to the WHO growth standards with Z-scores. Two types were studied: acute malnutrition (AM) and chronic malnutrition (CM). All participants were enrolled in a 6-month prospective interventional cohort, receiving Ready-To-Use Therapeutic Food, according to type of malnutrition. The nutritional intervention was offered until child growth reached -1.5 SD threshold. Six-month probability to catch up growth (>-2 SD) was assessed for AM using Kaplan-Meier curves and Cox model.

RESULTS

Among the 348 children screened, 198 (57%) were malnourished of whom 158 (80%) children were included: 97 (61%) for AM (35 with associated CM) and 61 (39%) with CM. Fifty-nine percent were boys, 97% were on antiretroviral therapy, median age was 9.5 years (Interquartile Range: 6.7-12.3). Among children with AM, 74% catch-up their growth at 6-month; probability to catch-up growth was greater for those without associated CM (adjusted Hazard Ratio = 1.97, CI 95%: 1.13 to 3.44). Anemia decreased significantly from 40% to 12% at the end of intervention (P < 0.001).

CONCLUSIONS

This macronutrient intervention showed 6-month benefits for weight gain and reduced anemia among these children mainly on antiretroviral therapy for years and aged greater than 5 years at inclusion. Associated CM slows down AM recovery and needs longer support. Integration of nutritional screening and care in the pediatric HIV-care package is needed to optimize growth and prevent metabolic disorders.

Molecular Evidence for Differential Long-term Outcomes of Early Life Severe Acute Malnutrition

BACKGROUND

Severe acute malnutrition (SAM) in infants may present as one of two distinct syndromic forms: non-edematous (marasmus), with severe wasting and no nutritional edema; or edematous (kwashiorkor) with moderately severe wasting. These differences may be related to developmental changes prior to the exposure to SAM and phenotypic changes appear to persist into adulthood with differences between the two groups. We examined whether the different response to SAM and subsequent trajectories may be explained by developmentally-induced epigenetic differences.

METHODS

We extracted genomic DNA from muscle biopsies obtained from adult survivors of kwashiorkor (n=21) or marasmus (n=23) and compared epigenetic profiles (CpG methylation) between the two groups using the Infinium® 450K BeadChip array.

FINDINGS

We found significant differences in methylation of CpG sites from 63 genes in skeletal muscle DNA. Gene ontology studies showed significant differential methylation of genes in immune, body composition, metabolic, musculoskeletal growth, neuronal function and cardiovascular pathways, pathways compatible with the differences in the pathophysiology of adult survivors of SAM.

INTERPRETATION

These findings suggest persistent developmental influences on adult physiology in survivors of SAM. Since children who develop marasmus have lower birth weights and after rehabilitation have different intermediary metabolism, these studies provide further support for persistent developmentally-induced phenomena mediated by epigenetic processes affecting both the infant response to acute malnutrition and later life consequences.

FUNDING

Supported by a Grant from the Bill and Melinda Gates Foundation (Global Health OPP1066846), Grand Challenge "Discover New Ways to Achieve Healthy Growth."

EVIDENCE BEFORE THIS STUDY

Previous research has shown that infants who develop either kwashiorkor or marasmus in response to SAM differ in birth weight and subsequently have different metabolic patterns in both infancy and adulthood.

ADDED VALUE OF THIS STUDY

This study demonstrates epigenetic differences in the skeletal muscle of adult survivors of marasmus versus kwashiorkor and these differences are in genes that may underlie the longer-term consequences.

IMPLICATIONS OF ALL THE AVAILABLE EVIDENCE

These data are compatible with the different clinical responses to SAM arising from developmentally-induced epigenetic changes laid down largely before birth and provide evidence for the predictive adaptive response model operating in human development.

Nutritional status and social behavior in preschool children: the mediating effects of neurocognitive functioning

Early malnutritional status has been associated with reduced cognitive ability in childhood. However, there are almost no studies on the effect of malnutrition on positive social behavior, and no tests of possible mediating mechanisms. This study tests the hypothesis that poor nutritional status is associated with impaired social functioning in childhood, and that neurocognitive ability mediates this relationship. We assessed 1553 male and female 3-year-olds from a birth cohort on measures of malnutrition, social behavior and verbal and spatial neurocognitive functions. Children with indicators of malnutrition showed impaired social behavior (p < .0001) as compared with children in the control group with adequate nutritional status. These associations even persisted after controlling for social adversity and parental education. Findings were not moderated by gender or ethnicity, and there was no interaction effect with parental education. A dose-response relationship was observed between degree of malnutrition and degree of social behavior, with increased malnutrition associated with more impaired social behavior. Neurocognitive ability was found to mediate the nutrition-social behavior relationship. The mediation effect of neurocognitive functioning suggests that poor nutrition negatively impacts brain areas that play important roles in developing positive social behavior. Findings suggest that reducing poor nutrition, alternatively promoting good nutrition, may help promote positive social behavior in early childhood during a critical period for social and neurocognitive development, with implications for improving positive health in adulthood.

Neurodevelopment: The Impact of Nutrition and Inflammation During Adolescence in Low-Resource Settings

Approximately 1 out of 5 children worldwide suffers from childhood malnutrition or stunting and associated health conditions, including an increased susceptibility to infections and inflammation. Due to improved early interventions, most children even in low-resource settings now survive early childhood malnutrition, yet exhibit continuing evidence of neurodevelopmental deficits, including poor school achievement and behavioral problems. These conditions are compounded in children who continue to be undernourished throughout the adolescent years. At present, these sequelae of malnutrition and infection are of major concern in the adolescent population, given that young people between the ages of 10 and 24 years represent nearly one-quarter of the world's population. Therefore, there is an urgent need to focus on the well-being of this age group and, in particular, on behavioral, cognitive, and brain disorders of adolescents who experienced malnutrition, infection, and inflammation prenatally, in early childhood, and during adolescence itself. Because one-third of all women globally become pregnant during their adolescent years, brain and behavioral disorders during this period can have an intergenerational impact, affecting the health and well-being of the next generation. This article summarizes the current state of knowledge and evidence gaps regarding childhood and adolescent malnutrition and inflammation and their impact on adolescent neurodevelopment, the limited evidence regarding nutrition and psychosocial interventions, and the role of resilience and protective factors in this age group. This overview should help to inform the development of new strategies to improve the neurodevelopmental outcomes of high risk adolescent populations.

Determinants of infant nutritional status in Dabat district, North Gondar, Ethiopia: A case control study

Background

Malnutrition is the top cause of global burden of disease, disability and mortality among infants. Over two-thirds of deaths of children globally occur during the first year of life (infancy). Malnutrition among infants is substantially high in Ethiopia. Therefore, this study is aimed to assess determinants of infant nutritional status.

Methods

A community based nested case-control study was conducted from February to June 2013 in Dabat district. A total of 80 cases and 320 controls (1:4 ratios) were studied. Relevant data was extracted from the community based survey data set. Anthroplus software was used to identify cases and controls. Determinants of infant nutritional status were identified using multivariate analysis.

Results

Among the total of 80 cases and 320 controls, more than half (52.5%) of the cases and the controls (53.8%) were males and females, respectively. Breast Feeding (BF) was started immediately after birth in only 43.8% of the cases. Nearly 94% of the mothers of the cases had no breast feeding information as part of Ante Natal Care (ANC) follow up. Maternal age (AOR: 0.29; 95% CI: 0.11–0.76), having radio (AOR: 0.43; 95% CI: 0.22–0.82), lack of toilet facility (AOR: 2.24; 95% CI: 1.16–4.33), deprivation of colostrum (AOR: 1.76; 95% CI: 1.01–1.06) and method of complementary feeding (AOR: 2.82; 95% CI: 1.33–5.99) were associated with wasting.

Conclusions

This study has found that inappropriate infant feeding; nutritional information gap and lack of toilet facility as significant predictors of malnutrition. Hence, joint interventions, including counseling of mothers about benefits of colostrum feeding and use of appropriate feeding method, toilet utilization and mass media such as radio possession, are needed to address the problem in Dabat district.

DNA Methylation Signatures of Early Childhood Malnutrition Associated With Impairments in Attention and Cognition

BACKGROUND

Early childhood malnutrition affects 113 million children worldwide, impacting health and increasing vulnerability for cognitive and behavioral disorders later in life. Molecular signatures after childhood malnutrition, including the potential for intergenerational transmission, remain unexplored.

METHODS

We surveyed blood DNA methylomes (~483,000 individual CpG sites) in 168 subjects across two generations, including 50 generation 1 individuals hospitalized during the first year of life for moderate to severe protein-energy malnutrition, then followed up to 48 years in the Barbados Nutrition Study. Attention deficits and cognitive performance were evaluated with the Connors Adult Attention Rating Scale and Wechsler Abbreviated Scale of Intelligence. Expression of nutrition-sensitive genes was explored by quantitative reverse transcriptase polymerase chain reaction in rat prefrontal cortex.

RESULTS

We identified 134 nutrition-sensitive, differentially methylated genomic regions, with most (87%) specific for generation 1. Multiple neuropsychiatric risk genes, including COMT, IFNG, MIR200B, SYNGAP1, and VIPR2 showed associations of specific methyl-CpGs with attention and IQ. IFNG expression was decreased in prefrontal cortex of rats showing attention deficits after developmental malnutrition.

CONCLUSIONS

Early childhood malnutrition entails long-lasting epigenetic signatures associated with liability for attention and cognition, and limited potential for intergenerational transmission.

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

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

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

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

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

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