Obesity or Stunting- Nutrition plays a critical role

It is a well known fact that children are a vulnerable segment of population and also very susceptible to morbidity due to infections. Various short term and long term health outcomes are associated with under-nutrition such as impaired immune function and consequent increased susceptibility to infections. Nutritional supplements can be served as an important source of nutrition as it promotes optimal growth and catch-up growth in children by meeting the unmet nutritional needs for energy, vitamins and minerals.

A balanced diet helps in the growth and development during the early childhood whereas, child malnutrition affects the cognitive function which leads to poverty due to lack of individuals ability to lead productive lives. Malnutrition affects 165 million children globally, resulting in poor cognition and stunted growth.

Source: https://devtechsys.com/insights/2017/06/05/combatting-chronic-malnutrition-in-guatemala/

Global Scenario

In May 2018, UNICEF, World Health Organization (WHO) and World Bank Group released the 2018 edition of the joint child malnutrition estimates for the 1990-2017 period, representing the global and regional figures. According to the report, it is estimated that approximately 151 million children under 5 years of age suffer from stunting globally while 38 million children were overweight (highlighted in Figure 1). Stunting is also associated with increased morbidity and mortality from infections, in particular pneumonia and diarrhea along with sepsis, meningitis, tuberculosis and hepatitis. On the other hand, there is a substantial increase in the prevalence of obesity. As per the report by WHO, there is a progressive rise in the prevalence of combined overweight and obesity in children. The prevalence has risen by 47.1% between 1980 and 2013. In 2014, 41 million children of the total population were affected by obesity and overweight.1, 2 Childhood obesity is linked to various medical conditions which include fatty liver disease, sleep apnea, Type 2 diabetes, asthma, cardiovascular disease, high cholesterol, gallstones, glucose intolerance and insulin resistance, skin conditions, menstrual abnormalities, impaired balance and orthopedic problems. 3

Indian Scenario

Young children in India suffer from some of the highest levels of stunting, underweight, and wasting observed in any country in the world, and 7 out of every 10 young children are anaemic. Inadequate feeding practices for children make it difficult to achieve the needed improvements in theirnutritional status, and nutrition programmes have been unable to make much headway in dealing with these serious nutritional problems. Several studies have explored health and nutritional status of children in India, which shows high rate of malnutrition. In India, the prevalence rate is 20.4 percent with 8.8 percent overweight, 11.1 percent obese and 0.4 percent suffering from morbid obesity. Although the prevalence rate of under-nutrition is much higher than that of over-nutrition, but the levels of over-nutrition are also on a rise.4, 5

STUNTING

Stunting refers to a chronic under-nutrition stage during the most crucial periods of growth and development in early childhood.If the percentage of children aged 0 to 59 months whose height for age is below minus two standard deviation, it is considered as moderate and severe stunting while minus three standard deviation results in severe stunting. A stunted child has a tendency of suffering from severe irreversible physical and cognitive damage.

As per UNICEF, stunting is not caused due to a single factor but rather caused by multiple factors which are interrelated to one another. The major contributor to stunting is diets with inadequate quality and quantity. Deficiency of certain micronutrients such as zinc is the major factor associated with stunting. WHO reported that children who experience high growth disorders are mainly due to inadequate food intake and also suffer repeated infectious diseases.Early childhood is a crucial period where there are increasing needs of energy and nutrients in response to metabolic increase due to the growth process. Several studies show that most of the stunted children consume foods under nutritional recommendations. Various socio-economic factors such as poverty, large number of family members or living in a rural or suburban area make the growth disorders difficult to cope, which eventually lead to stunting. Macronutrients such as carbohydrates, proteins and fats are required by the human body for energy and support for growth while the micronutrients are necessary for the proper functioning of the body and growth of various cells. Lack of micronutrients such as vitamin A, vitamin C, iron, zinc and calcium are considered to be the most determined factors in the incidence of stunting due to growth disorders.

Fig.1: Worldwide burden of Malnutrition

OBESITY

A rapid epidemiological and nutritional transition has been seen in 21st century which is characterized by persistent nutritional deficiencies, as evidenced by the prevalence of stunting. Concomitantly, a continuous rise in the prevalence of obesity and other nutrition related chronic diseases have been reported. Childhood obesity has reached epidemic proportion in developed countries, and developing countries are not far behind. According to the worldwide estimate over22 million children under the age of 5 are obese. Obesity occurs due to an imbalance between energy intake and expenditure, with an increase in positive energy balance being closely associated with the lifestyle adopted and the dietary intake preferences. 3

The Indian population is still struggling with the burden of malnutrition but the problem caused by over-nutrition is a crucial matter which cannot be overlooked. This problem must be addressed by taking effective actions involving the public, private and health professional and non-governmental sectors.6

The major factors linked to childhood obesity include dietary intake, physical activity and sedentary behavior. The impact of such factors is moderated by age, gender, family characteristics such as parenting style.

Nutrient Intake:

Stunting and Obesity is considered to be one of the biggest challenges among the epidemics facing the world as it has several downstream health consequences. Few evidence suggests that nutrition specific interventions could reduce child stunting by 20%. The various interventions include:

  • Folic acid supplementation
  • Iron and iron-folic acid supplementation
  • Multiple micronutrient supplementation
  • Calcium supplementation
  • Iodine fortification
  • Maternal supplementation with balanced energy and protein
  • Neonatal vitamin K administration
  • Vitamin A supplementation

Proteins are known to be an important component of every living cell. Children require enough energy, protein and nutrients to grow. Sometimes children need extra nutrition in order to promote catch up growth or may be due to increased needs from prolonged illness. As per the report by the National Institute of Nutrition (Indian Council of Medical Research), the recommended dietary allowance for protein in young children should be between 16.7g to 40.4g per day. On the other hand, dietary fibers are also known to show health benefits in young children. Several studies have reported a positive effect of dietary fiber intake in the treatment for constipation in children. In a Hong Kong based study, it was found that almost 30% children with low dietary fiber intake had constipation. In a similar study conducted on Irish children, it was found that the prevalence rate of constipation was as twice as high in children with inadequate or poor dietary fiber intake. Thus, several evidences support an association between low intakes of dietary fiber and high prevalence rate of constipation in young children. 7

A healthy balanced diet helps to maintain or improve overall health. A balanced diet is one which provides equal proportion of essential nutrition that a human body needs for a good health. During the first 6 months of life, infants should be breastfed and continuously until 2 years of age.8 Figure 2 depicts the recommended serving of food items which provide adequate amount of nutrition required for the catch up growth of children.

Fig.2: Diet Pyramid

Nowadays, flavored all-in-one nutritional supplemental drinks for children are easily available in the market. Nutritional supplements or complementary foods are defined as food based complements to the diet that can be mixed with or consumed in addition to the diet and the purpose of which is to add nutritional value. Parents can treat their picky eaters with these supplemental drinks to ensure their child doesn’t lack any nutrient. Nutritional supplements not only can improve growth and physical health of children, but also are considered to be important for their early development, including cognition. Many research studies suggest that childhood supplementation with multiple micronutrients or adding multiple micronutrients to food appeared to have a benefit.9

Since one of the most contributing parameters to growth is appropriate nutrition, the importance of using nutritional supplements for optimal growth and development cannot be overlooked. The recommended dietary intakes of nutrients are set by the dietary guidelines. Table 1 depicts the tolerable nutrient intake for different age group. Many studies highlights a variation in the RDA for Indian children and international comparison, hence India needs to modify the nutritional recommendations accordingly, to avoid any consequences of malnutrition.

Group

Category

Proteins (g/day)

Vit. B6 (mg/day)

Vit. B12 (µg/day)

Iron (mg/day)

Calcium (mg/day)

Zinc (mg/day)

Children

1-3 yrs

16.7

 

0.9

0.2-1.0

9

600

5

4-6yrs

20.1

13

7

7-9 yrs

29.5

1.6

16

8

Boys

10-12 yrs

39.9

 

1.6

21

800

9

Girls

10-12 yrs

40.4

27

9

Table 1: Recommended Dietary Allowance (RDA) Chart for different age group

To summarize, eating is an essential component for healthy growth and development. The food choices made by children and diet composition impact the health status during development and potentially later life. Dietary supplements can be consumed by the picky eaters who are unable to ingest the full amount of nutrients needed as part of his/her diet. The children consuming ONS should be regularly reviewed by the healthcare professional in order to ensure that the child doesn’t consume excess nutrients.

References:

  1. Joint child malnutrition estimates 2018 (UNICEF-WHO-WB).
  2. World Health Organization. Prioritizing areas for action in the field of population-based prevention of childhood obesity: a set of tools for Member States to determine and identify priority areas for action. 2012. Assessed from:http://datatopics.worldbank.org/child-malnutrition/. Accessed on 18/2/19
  3. Sahoo K, Sahoo B, Choudhury AK, Sofi NY, Kumar R, Bhadoria AS. Childhood obesity: causes and consequences. J Family Med Prim Care. 2015;4(2):187-92.
  4. Kanjilal, B., et al. Nutritional status of children in India: household socio-economic condition as the contextual determinant. International journal for equity in health. 2010: 9(19).
  5. Singla A.K. Under-nutrition to over-nutrition: the tilting scales of nutrition status in india. 2012
  6. Kar S.S, Kar S.S. Prevention of childhood obesity in India: Way Forward. Journal of Natural Science, Biology and Medicine. Vol 6 Issue 1
  7. Kranz et al. What Do We Know About Dietary Fiber Intake in Children and Health? The Effects of Fiber Intake on Constipation, Obesity, and Diabetes in Children. Advances in nutrition (Bethesda, Md.). (2012). 3. 47-53.
  8. World Health Organization. Reducing stunting in children: equity considerations for achieving the Global Nutrition Targets 2025. 2018
  9. Rivera JA, Hotz C, González-Cossío T, Neufeld L, García-Guerra A. The effectof micronutrient deficiencies on child growth: a review of results fromcommunity-based supplementation trials. J Nutr. 2003 Nov;133(11)
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