Child undernutrition in affluent societies: what are we talking about?

In this paper we set out to explore the prevalence of child undernutrition found in community studies in affluent societies, but a preliminary literature review revealed that, in the absence of a gold standard method of diagnosis, the prevalence largely depends on the measure, threshold and the growth reference used, as well as age. We thus go on to explore describe the common clinical ‘syndromes’ of child undernutrition: wasting, stunting and failure to thrive (weight faltering) and how we have used data from two population-based cohort studies, this paper to explore how much these different ‘syndromes’ overlap and the extent to which they reflect true undernutrition. This analysis revealed that when more than one definition is applied to the same children, a majority are below the lower threshold for only one measure. However, those with both weight faltering and low BMI in infancy, go on in later childhood to show growth and body composition patterns suggestive of previous undernutrition. In older children there is even less overlap and most children with either wasting or low fat seem to be simply growing at one extreme of the normal range. We conclude that in affluent societies the diagnosis of undernutrition is only robust when it relies on a combination of both, that is decline in weight or BMI centile and wasting

The Spanish strategy for nutrition, physical activity and the prevention of obesity

The prevalence and increasing trends of obesity in Spain are a matter of concern. In adults, the prevalence of obesity and overweight is 14·5 and 38·5 %, respectively, whereas in children and adolescents it is 13·9 and 26·3 %. This situation prompted the Spanish Ministry of Health and Consumer Affairs to draw up the Strategy for Nutrition, Physical Activity and the Prevention of Obesity (NAOS), which aims to improve the diet and encourage the regular practice of physical activity by all citizens, with special emphasis on children. Coordinated by the Spanish Food Safety Agency and the General Directorate of Public Health, a wide range of stakeholders participated in drafting the Strategy through a broad consultative process. Anchored on the core goal of adopting a lifelong perspective in the prevention and control of obesity, NAOS encompasses recommendations for action in four fields: family and community, schools, private sector, and the health system. Launched on 10 February 2005, the Strategy will undergo careful monitoring and evaluation. A newly created Obesity Observatory will carry out epidemiological surveillance, define indicators to measure impact of interventions, facilitate the exchange of experiences among different initiatives, identify research priorities, monitor adherence and application of the self-regulation agreements, and conduct rigorous evaluation of initiatives to identify those that are successful and should be prioritized. To our knowledge, NAOS is the first strategy of its kind in Europe and we recommend it as an example to be followed by countries that, like Spain, face the challenge of combating the pervasive epidemic of obesit

Prevalence and trends of stunting among pre-school children, 1990-2020

Abstract Objective To quantify the prevalence and trends of stunting among children using the WHO growth standards. Design Five hundred and seventy-six nationally representative surveys, including anthropometric data, were analysed. Stunting was defined as the proportion of children below −2sd from the WHO length- or height-for-age standards median. Linear mixed-effects modelling was used to estimate rates and numbers of affected children from 1990 to 2010, and projections to 2020. Setting One hundred and forty-eight developed and developing countries. Subjects Boys and girls from birth to 60 months. Results In 2010, it is estimated that 171 million children (167 million in developing countries) were stunted. Globally, childhood stunting decreased from 39·7 (95 % CI 38·1, 41·4) % in 1990 to 26·7 (95 % CI 24·8, 28·7) % in 2010. This trend is expected to reach 21·8 (95 % CI 19·8, 23·8) %, or 142 million, in 2020. While in Africa stunting has stagnated since 1990 at about 40 % and little improvement is anticipated, Asia showed a dramatic decrease from 49 % in 1990 to 28 % in 2010, nearly halving the number of stunted children from 190 million to 100 million. It is anticipated that this trend will continue and that in 2020 Asia and Africa will have similar numbers of stunted children (68 million and 64 million, respectively). Rates are much lower (14 % or 7 million in 2010) in Latin America. Conclusions Despite an overall decrease in developing countries, stunting remains a major public health problem in many of them. The data summarize progress achieved in the last two decades and help identify regions needing effective intervention

Comparison of estimates of under-nutrition for pre-school rural Pakistani children based on the WHO standard and the National Center for Health Statistics (NCHS) reference

Objective: To compare estimates of under-nutrition among pre-school Pakistani children using the WHO growth standard and the National Center for Health Statistics (NCHS) reference. Design: Prevalence of stunting, wasting and underweight as defined by WHO and NCHS standards are calculated and compared. Setting: The data are from two cross-sectional surverys conducted in the early 1990s, the time frame for setting the baseline for the Millennium Development Goals: (i) National Health Survey of Pakistan (NHSP) assessed the health status of a nationally representative sample and (ii) Thatta Health System Research Project (THSRP) was a survey in Thatta, a rural district of Sindh Province. Subejcts: In all, 1533 and 1051 children aged 0-35 months from national and Thatta surveys, respectively. Results: WHO standard gave a significantly higher prevalence of stunting for both national [36.7 (95% CI 33.2, 40.2)] and Thatta surveys [52.9 (95% CI 48.9, 56-9)] compared to the NCHS reference [national 29.1 (95% CI 25.9, 32.2) and Thatta: 44.8 (95% CI 41.1, 48.5), respectively]. It also gave significantly higher prevalence of wasting for the Thatta survey [22.9 (95% CI 20.3, 25.5)] compared to the NCHS reference [15.7 (95% CI 13.5, 17.8)]. Differences due to choice of standard were pronounced during infancy and for severely wasted and severely stunted children. Conclusions: Pakistan should switch to the robustly constructed and up-to-date WHO growth standard for assessing under-nutrition. New growth charts should be introduced along with training for health workers. This has implications for nutritional intervention programmes, for resetting the country\u27s targets for Millennium Development Goal 1 and for monitoring nutritional trends

Impact of the shift from NCHS growth reference to WHO(2006) growth standards in a therapeutic feeding programme in Niger.

OBJECTIVES: To describe the implementation of the WHO(2006) growth standards in a therapeutic feeding programme. METHODS: Using programme monitoring data from 21,769 children 6-59 months admitted to the Médecins Sans Frontières therapeutic feeding programme during 2007, we compared characteristics at admission, type of care and outcomes for children admitted before and after the shift to the WHO(2006) standards. Admission criteria were bipedal oedema, MUAC <110 mm, or weight-for-height (WFH) of <-70% of the median (NCHS) before mid-May 2007, and WFH <-3 z score (WHO(2006)) after mid-May 2007. RESULTS: Children admitted with the WHO(2006) standards were more likely to be younger, with a higher proportion of males, and less malnourished (mean WFH -3.6 z score vs. mean WFH -4.6 z score). They were less likely to require hospitalization or intensive care (28.4%vs. 77%; 12.8%vs. 36.5%) and more likely to be treated exclusively on an outpatient basis (71.6%vs. 23%). Finally, they experienced better outcomes (cure rate: 89%vs. 71.7%, death rate: 2.7%vs. 6.4%, default rate: 6.7%vs. 12.3%). CONCLUSIONS: In this programme, the WHO(2006) standards identify a larger number of malnourished children at an earlier stage of disease facilitating their treatment success

Low castes have poor access to visceral leishmaniasis treatment in Bihar, India

Objectives  Bihar, the poorest state in India, concentrates most of the visceral leishmaniasis (VL) cases in the country. A large proportion of the poor rural communities where VL is endemic are marginalized by their socio-economic status, intrinsically related to the caste system. In this study, we evaluated whether people from low socio-economic strata had difficulties accessing VL treatment in Bihar. As a secondary outcome, we evaluated whether people delaying their VL treatment had poorer clinical indicators at admission. Methods  Data on 2187 patients with VL treated by Médecins Sans Frontières (MSF) in Vaishali district from July 2007 to December 2008 were analysed. Patients who reported having onset of symptoms ≥8 weeks before admission were defined as 'late presenters'. Logistic regression models were used to evaluate whether low castes had higher risk to be 'late presenters' compared to the rest of castes and whether 'late presenters' had poorer indicators at admission (i.e. haemoglobin level, spleen size). Results  After adjusting for age, gender and distance to VL treatment facility, Mushars (the lowest caste in Bihar) had twice the odds to be 'late presenters' compared to the rest of castes (OR 2.05, 95% CI: 1.24-2.38). Subjects that had VL symptoms for ≥8 weeks had a larger spleen and lower haemoglobin level than those that were treated earlier. Conclusion  Low castes have poor access to VL treatment in Bihar, and late presenters have poorer clinical indicators at admission. These findings have implications at individual and community levels and should stimulate targeted VL control programmes to ensure that marginalized communities in Bihar are properly treated

Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes

Abstract Objectives To compare growth patterns and estimates of malnutrition based on the World Health Organization (WHO) Child Growth Standards (‘the WHO standards') and the National Center for Health Statistics (NCHS)/WHO international growth reference (‘the NCHS reference'), and discuss implications for child health programmes. Design Secondary analysis of longitudinal data to compare growth patterns (birth to 12 months) and data from two cross-sectional surveys to compare estimates of malnutrition among under-fives. Settings Bangladesh, Dominican Republic and a pooled sample of infants from North America and Northern Europe. Subjects Respectively 4787, 10 381 and 226 infants and children. Results Healthy breast-fed infants tracked along the WHO standard's weight-for-age mean Z-score while appearing to falter on the NCHS reference from 2 months onwards. Underweight rates increased during the first six months and thereafter decreased when based on the WHO standards. For all age groups stunting rates were higher according to the WHO standards. Wasting and severe wasting were substantially higher during the first half of infancy. Thereafter, the prevalence of severe wasting continued to be 1.5 to 2.5 times that of the NCHS reference. The increase in overweight rates based on the WHO standards varied by age group, with an overall relative increase of 34%. Conclusions The WHO standards provide a better tool to monitor the rapid and changing rate of growth in early infancy. Their adoption will have important implications for child health with respect to the assessment of lactation performance and the adequacy of infant feeding. Population estimates of malnutrition will vary by age, growth indicator and the nutritional status of index population

Worldwide implementation of the WHO Child Growth Standards

Abstract Objective To describe the worldwide implementation of the WHO Child Growth Standards (‘WHO standards'). Design A questionnaire on the adoption of the WHO standards was sent to health authorities. The questions concerned anthropometric indicators adopted, newly introduced indicators, age range, use of sex-specific charts, previously used references, classification system, activities undertaken to roll out the standards and reasons for non-adoption. Setting Worldwide. Subjects Two hundred and nineteen countries and territories. Results By April 2011, 125 countries had adopted the WHO standards, another twenty-five were considering their adoption and thirty had not adopted them. Preference for local references was the main reason for non-adoption. Weight-for-age was adopted almost universally, followed by length/height-for-age (104 countries) and weight-for-length/height (eighty-eight countries). Several countries (thirty-six) reported newly introducing BMI-for-age. Most countries opted for sex-specific charts and the Z-score classification. Many redesigned their child health records and updated recommendations on infant feeding, immunization and other health messages. About two-thirds reported incorporating the standards into pre-service training. Other activities ranged from incorporating the standards into computerized information systems, to providing supplies of anthropometric equipment and mobilizing resources for the standards' roll-out. Conclusions Five years after their release, the WHO standards have been widely scrutinized and implemented. Countries have adopted and harmonized best practices in child growth assessment and established the breast-fed infant as the norm against which to assess compliance with children's right to achieve their full genetic growth potentia

Ebola research funding: a systematic analysis, 1997–2015

Background: The latest outbreak of Ebola in West Africa overwhelmed the affected countries, with the impact on health extending far beyond Ebola–related deaths that have exceeded 11?000. The need to promptly mobilise resources to control emerging infections is widely recognized. Yet, data on research funding for emerging infections remains inadequately documented.Methods: We defined research investment as all funding flows for Ebola and/or Marburg virus from 1997 to April 2015 whose primary purpose was to advance knowledge and new technologies to prevent or cure disease. We sourced data directly from funding organizations and estimated the investment in 2015 US dollars (US$).Results: Funding for Ebola and Marburg virus research in 1997 to 2015 amounted to US$ 1.035 billion, including US$435.4 million (42.0$ 758.8 million (73.1%), philanthropic sources US$65.1 million (6.3$ 213.8 million (20.6%). Prior to the Ebola outbreak in 2014, pre–clinical research dominated research with US$443.6 million (73.9$ 399.1 million, with 61.3% awarded for vaccine research, 29.2% for novel therapeutics research such as antivirals and convalescent blood products, and 9.5% for diagnostics research. Research funding and bibliometric output were moderately associated (Spearman's ??=?0.5232, P?=?0.0259), however number of Ebola cases in previous outbreaks and research funding (??=?0.1706, P?=?0.4985) and Ebola cases in previous outbreaks and research output (??=?0.3020, P?=?0.0616) were poorly correlated.Conclusion: Significant public and philanthropic funds have been invested in Ebola and Marburg virus research in 2014 and 2015, following the outbreak in West Africa. Long term, strategic vision and leadership are needed to invest in infections with pandemic potential early, including innovative financing measures and open access investment data to promote the development of new therapies and technologies

Prevalence and Determinants of Obesity among Primary School Children in Dar es Salaam, Tanzania.

Childhood obesity has increased dramatically and has become a public health concern worldwide. Childhood obesity is likely to persist through adulthood and may lead to early onset of NCDs. However, there is paucity of data on obesity among primary school children in Tanzania. This study assessed the prevalence and determinants of obesity among primary school children in Dar es Salaam. A cross sectional study was conducted among school age children in randomly selected schools in Dar es Salaam. Anthropometric and blood pressure measurements were taken using standard procedures. Body Mass Index (BMI) was calculated as weight in kilograms divided by the square of height in meters (kg/m2). Child obesity was defined as BMI at or above 95th percentile for age and sex. Socio-demographic characteristics of children were determined using a structured questionnaire. Logistic regression was used to determine association between independent variables with obesity among primary school children in Dar es Salaam. A total of 446 children were included in the analysis. The mean age of the participants was 11.1±2.0 years and 53.1% were girls. The mean BMI, SBP and DBP were 16.6±4.0 kg/m2, 103.9±10.3mmHg and 65.6±8.2mmHg respectively. The overall prevalence of child obesity was 5.2% and was higher among girls (6.3%) compared to boys (3.8%). Obese children had significantly higher mean values for age (p=0.042), systolic and diastolic blood pressures (all p<0.001). Most obese children were from households with fewer children (p=0.019) and residing in urban areas (p=0.002). Controlling for other variables, age above 10 years (AOR=3.3, 95% CI=1.5-7.2), female sex (AOR=2.6, 95% CI=1.4-4.9), urban residence (AOR=2.5, 95% CI=1.2-5.3) and having money to spend at school (AOR=2.6, 95% CI=1.4-4.8) were significantly associated with child obesity. The prevalence of childhood obesity in this population was found to be low. However, children from urban schools and girls were proportionately more obese compared to their counterparts. Primary preventive measures for childhood obesity should start early in childhood and address socioeconomic factors of parents contributing to childhood obesity