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

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 populations.     

Excluding infants under 6 months of age from surveys: impact on prevalence of pre-school undernutrition

OBJECTIVE: Infants aged 0-5 months are not systematically included in assessments of child nutritional status and are generally excluded from surveys conducted in emergencies. We estimated the impact of excluding 0-5-month-old infants on the prevalence of stunting, wasting and underweight among children under 5 years (U5) and under 3 years (U3) of age. DESIGN: Comparison of the prevalence of stunting, wasting and underweight in U5 and U3 with or without inclusion of the age group 0-5 months. SETTING: Demographic and Health Surveys and Multiple Indicator Cluster Surveys from 76 developing countries and countries in transition. SUBJECTS: Children under 3 or under 5 years of age included in the surveys.Results Excluding 0-5-month-old infants resulted in an overestimation of the prevalence of stunting, wasting and underweight in U5 of 3.0, 0.3 and 2.6 percentage points, respectively, and of 4.8, 1.0 and 5.2 percentage points, respectively, in U3. The overestimation for wasting was negligible. The regions showing the highest overestimations for stunting and underweight were Asia and sub-Saharan Africa. Overall, countries with high prevalences of stunting and underweight showed especially large overestimations. The prevalence of underweight in infants aged 0-5 months was correlated with the prevalence of low maternal body mass index. CONCLUSION: All surveys, even in situations of nutrition emergency, should include 0-5-month-old infants. Strictly comparable age ranges are essential in nutrition surveys for monitoring trends and evaluating programme impact. Greater awareness of prenatal and early child undernutrition is needed among policy-makers.     

Determinants of nutrition improvement in a large-scale urban project: a follow-up study of children participating in the Senegal Community Nutrition Project

OBJECTIVE: To study individual determinants of differential benefit from the Senegal Community Nutrition Project (CNP) by monitoring improvement in children's weight-for-age index (WA) or underweight status (WA < -2 Z-scores) during participation. DESIGN: A follow-up study using the CNP child monitoring data. Linear general models compared variations in WA according to 14 factors describing the beneficiaries and CNP services. SETTING: Poor neighbourhoods of Diourbel, a large city in Senegal, West Africa. Over a 6-month period, the CNP provided underweight or nutritionally at-risk 6-35-month-old children with monthly growth monitoring and promotion and weekly food supplementation, provided that mothers attended weekly nutrition education sessions. SUBJECTS: All the children who participated in the first two years of the project (n=4084). RESULTS: Mean WA varied from -2.13 (standard deviation (SD) 0.82) to -1.58 (SD 0.81) Z-scores between recruitment and the end of the follow-up. The lower the child's initial WA, the greater was their increase in WA but the lower was the probability of recovery from underweight. Only 61% of underweight children recovered. Six months of CNP services may not be sufficient for catch-up growth of severely underweight children. The number of food supplement rations received was not a direct indicator of the probability of recovery. After adjustment for services received and initial WA, probability of recovery was lower in girls, in younger children, in twins and when mothers belonged to a specific ethnic group. CONCLUSIONS: Determinants of benefit from CNP differed from the risk factors for underweight. Identification of participants with a lower probability of recovery can help improve outcome. Moreover, an explanation for the lack of recovery could be that many underweight children are stunted but not necessarily wasted.     

Inadequate dietary intake is not the cause of stunting amongst young children living in an informal settlement in Gauteng and rural Limpopo Province in South Africa: the NutriGro study

OBJECTIVE: To measure dietary intakes of young children aged 12-24 months and to determine the impact of poor diets on stunting. DESIGN: A quantitative food-frequency questionnaire was adapted, tested and standardised. Trained enumerators conducted in-depth interviews with the mothers/caregivers of the children. Forty stunted children in urban informal settlements and 30 stunted children in rural areas were selected and pair-matched with controls. The data were captured on the Food Finder Program of the Medical Research Council. RESULTS: In both urban and rural areas, the diet of stunted and non-stunted groups did differ significantly and all diets were of poor nutritional quality. CONCLUSION: Diets in both areas resembled the recommended prudent diet, i.e. low in fat and high in carbohydrates. Poor quality diets were not the primary cause of stunting.     

Paternal smoking is associated with increased risk of child malnutrition among poor urban families in Indonesia

OBJECTIVE: Paternal smoking is highly prevalent in Asia, and tobacco may account for a large proportion of household expenditures among poor families. We sought to characterise the relationship between paternal smoking, child malnutrition and food expenditures. DESIGN: Data on smoking, household expenditures and child malnutrition were examined in a stratified multistage cluster sample of households in the Indonesia nutrition surveillance system. Main outcome measures were child wasting (weight-for-height Z-score < - 2), underweight (weight-for-age Z-score < - 2) and stunting (height-for-age Z-score < - 2), and severe wasting, underweight and stunting (defined by respective Z-scores < - 3). SETTING: In total, 175,583 households from urban slum areas in Indonesia. SUBJECTS: Children 0-59 months of age. RESULTS: The prevalence of paternal smoking was 73.8%. After adjusting for child gender and age, maternal age and education, and weekly per capita household expenditures, paternal smoking was associated with child stunting (odds ratio (OR) = 1.11, 95% confidence interval (CI) 1.08-1.14, P < 0.0001), severe wasting (OR = 1.17, 95% CI 1.03-1.33, P = 0.018) and severe stunting (OR = 1.09, 95% CI 1.04-1.15, P < 0.001). In households where the father was a smoker, tobacco accounted for 22% of weekly per capita household expenditures, with less money spent on food compared with households in which the father was a non-smoker. CONCLUSIONS: Among poor families in urban slum areas of Indonesia, paternal smoking diverts household money from food to tobacco and exacerbates child malnutrition.     

BRAC initiative towards promoting gender and social equity in health: a longitudinal study of child growth in Matlab, Bangladesh

OBJECTIVE: To explore the effect of BRAC (formerly Bangladesh Rural Advancement Committee) initiatives towards promoting gender and social equity in health among children of poor mothers who are BRAC members. DESIGN: A cohort of 576 children from the prospective study of a BRAC- International Centre for Diarrhoeal Disease Research, Bangladesh joint research project was analysed. Data were collected three times during 1995-1996 with approximately 4-month intervals. Stunting, defined as height-for-age below minus two standard deviations from the reference median, was the outcome health measure. The study children were stratified into three groups according to their mother's social and BRAC membership status: poor and BRAC member (BM), poor non-member (TG) and non-poor non-member (NTG). SETTING: Matlab, rural area of Bangladesh. SUBJECTS: Children aged 6-72 months. RESULTS: The overall prevalence of stunting was 76%; the highest prevalence was found among TG (84.6%) children and no significant difference was observed between BM and NTG children (67.3% and 69.4%, respectively). In all groups, a significantly larger proportion of girls was stunted compared with boys in the first round. Group-level analysis showed that stunting decreased among all children except BM boys at the end of third round, with the largest decline among BM girls. In contrast, stunting prevalence increased among BM boys. A similar trend was found in the individual-level analysis, where a larger proportion of BM girls recovered from stunting compared with other groups and no recovery was observed among BM boys. At the end of the third round, the nutritional status of BM girls was almost equal to that of the BM boys, while gender inequity remained large among TG and NTG children. CONCLUSION: The BRAC initiative appeared to contribute to a significant equity gain in health for girls, as well as to decreased differences in ill health between the poor and the non-poor.     

Does living in an urban environment confer advantages for childhood nutritional status? Analysis of disparities in nutritional status by wealth and residence in Angola, Central African Republic and Senegal

OBJECTIVE: The purpose of this paper is to examine the relationship between childhood undernutrition and poverty in urban and rural areas. DESIGN: Anthropometric and socio-economic data from Multiple Indicator Cluster Surveys in Angola-Secured Territory (Angola ST), Central African Republic and Senegal were used in this analysis. The population considered in this study is children 0-59 months, whose records include complete anthropometric data on height, weight, age, gender, socio-economic level and urban or rural area of residence. In addition to simple urban/rural comparisons, the population was stratified using a wealth index based on living conditions and asset ownership to compare the prevalence, mean Z-score and odds ratios for stunting and wasting. RESULTS: In all cases, when using a simple urban/rural comparison, the prevalence of stunting was significantly higher in rural areas. However, when the urban and rural populations were stratified using a measure of wealth, the differences in prevalence of stunting and underweight in urban and rural areas of Angola ST, Central African Republic and Senegal disappeared. Poor children in these urban areas were just as likely to be stunted or underweight as poor children living in rural areas. The odds ratio of stunting in the poorest compared with the richest quintile was 3.4, 3.2 and 1.5 in Angola ST, Senegal and Central African Republic, respectively. CONCLUSIONS: This paper demonstrates that simple urban/rural comparisons mask wide disparities in subgroups according to wealth. There is a strong relationship between poverty and chronic undernutrition in both urban and rural areas; this relationship does not change simply by living in an urban environment. However, urban and rural living conditions and lifestyles differ, and it is important to consider these differences when designing programmes and policies to address undernutrition.     

Prevalence and determinants of stunting and overweight in 3-year-old black South African children residing in the Central Region of Limpopo Province, South Africa

OBJECTIVES: To determine the prevalence of stunting, wasting and overweight and their determinants in 3-year-old children in the Central Region of Limpopo Province, South Africa. DESIGN: Prospective cohort study. SETTING: Rural villages in the Central Region of the Limpopo Province, South Africa. SUBJECTS: One hundred and sixty-two children who were followed from birth were included in the study. Anthropometric measurements and sociodemographic characteristics of the children were recorded. RESULTS: Height-for-age Z-scores were low, with a high prevalence of stunting (48%). The children also exhibited a high prevalence of overweight (22%) and obesity (24%). Thirty-one (19%) children were both stunted and overweight. Gaining more weight within the first year of life increased the risk of being overweight at 3 years by 2.39 times (95% confidence interval (CI) 1.96-4.18) while having a greater length at 1 year was protective against stunting (odds ratio (OR) 0.41; 95% CI 0.17-0.97). Having a mother as a student increased the risk for stunting at 3 years by 18.21 times (95% CI 9.46-34.74) while having a working mother increased the risk for overweight by 17.87 times (95% CI 8.24-38.78). All these factors also appeared as risks or as being protective in children who were both overweight and stunted, as did living in a household having nine or more persons (OR 5.72; 95% CI 2.7-12.10). CONCLUSION: The results of this study highlight the importance of evaluating anthropometric status in terms of both stunting and overweight. Furthermore, it is important to realise the importance of normal length and weight being attained at 1 year of age, since these in turn predict nutritional status at 3 years of age.     

Effectiveness of a community-based intervention to improve nutrition in young children in Senegal: a difference in difference analysis

There are few studies of community growth promotion as a means of addressing malnutrition that are based on longitudinal analysis of large-scale programmes with adequate controls to construct a counterfactual. The current study uses a difference in difference comparison of cohorts to assess the impact on the proportion of underweight children who lived in villages receiving services provided by the Senegal Nutrition Enhancement Project between 2004 and 2006. The project, designed to extend nutrition and growth promotion intervention into rural areas through non-governmental organisation service providers, significantly lowered the risk of a child having a weight more than 2 sd below international norms. The odds ratio of being underweight for children in programme villages after introduction of the intervention was 0.83 (95% CI 0.686, 1.000), after controlling for regional trends and village and household characteristics. Most measured aspects of health care and health seeking behaviour improved in the treatment relative to the control.     

Effect of economic inequality on chronic childhood undernutrition in Ghana

OBJECTIVE: Food insecurity and undernutrition remain particularly severe in developing countries where improvements in economic conditions have tended to benefit the advantaged groups and resulted in widespread inequalities in health. This study examined how economic inequality is associated with chronic childhood undernutrition. DESIGN: A child was defined as chronically undernourished (stunted) if his or her height-for-age index was more than two standard deviations below the reference median. Household economic status was measured by an index based on household ownership of durable assets. Bivariate and multivariate analyses were used to estimate the effects of household economic status on stunting. SETTING: A nationally representative sample of 6251 household interviews in Ghana.Subjects A total of 3077 children aged 0-59 months included in the 2003 Ghana Demographic and Health Survey. RESULTS: Children in the poorest 20% of households are more than twice as likely to suffer from stunting as children in the richest 20% of households independent of the child's age, sex, birth order, breast-feeding duration, birth weight; mother's age at childbirth, body mass index, education; and household access to safe drinking water, hygienic toilet facilities, residence and geographic region (odds ratio = 2.3; 95% confidence interval 1.4-3.7). Also children in the next poorest and in the middle quintiles are significant more likely to be chronically undernourished than children in the richest 20% of households. CONCLUSION: This study concludes that economic inequality is strongly associated with chronic childhood undernutrition; and reducing economic inequalities and making services more accessible to the poor will be key to improving the health and nutritional status of children in Ghana.     

Ethnic differences in body mass index and associated factors of adolescents from minorities in Oslo, Norway: a cross-sectional study

OBJECTIVES: To examine ethnic differences in body mass index (BMI), food habits and physical activity, and determine the factors contributing to differences in BMI. DESIGN AND METHOD: In 2000-2001, 7343 (response rate 88%) 15- and 16-year-old students, enrolled in lower secondary schools in Oslo, participated in the cross-sectional Oslo Health Study. Of these participants, 1719 were defined as ethnic minorities. RESULTS: Significant gender and ethnic differences in mean BMI were observed. Of the ethnic minority adolescents, 5.8% were underweight (<5th percentile of the US Centers for Disease Control and Prevention (CDC)/National Center for Health Statistics (NCHS) reference distribution) and 9.1% were overweight (>85th percentile of the US CDC/NCHS reference distribution). BMI was not significantly associated with either socio-economic factors or physical activity. Food habits and physical activity differed with ethnicity but not with socio-economic factors. An ordinal regression showed that girls from East Asia (odds ratio (OR) 0.4) and boys from sub-Saharan Africa (OR 0.4) had lower BMI than the Western group. Among girls, higher BMI was associated with less frequent consumption of chocolates and sweets, full-fat milk and breakfast (OR 2.4, 1.7 and 1.7, respectively). Higher BMI, for both boys and girls, was associated with current and past dieting (OR 3.7 and 4.2, respectively). CONCLUSIONS: Adolescent food habits and physical activity varied by gender and ethnicity but not with socio-economic factors. BMI was associated with ethnicity, gender and food habits, but no significant relationship was observed with socio-economic factors or physical activity. Ethnicity, in addition to gender, should be taken into consideration when studying BMI and associated factors among adolescents.     

Early introduction of water and complementary feeding and nutritional status of children in northern Senegal

OBJECTIVE: Malnutrition is responsible globally for 60% of deaths among children under 5 years and is often attributed to suboptimal feeding practices. In response, the World Health Organization recommends exclusive breast-feeding for the first 6 months of life. The objective of this study was to determine if an association exists between the early introduction of water and complementary foods (CFs) and the nutritional status of children in northern Senegal. DESIGN/SETTING/SUBJECTS: A cross-sectional study of 374 children in the Podor Health District between the ages of 6 and 23 months was conducted. Knowledge and behaviours of mothers regarding introduction of water and CFs were assessed via individual interviews. RESULTS: Water was introduced to about 85% of the children in the first 3 months of life and 62% were fed CFs before 6 months. Overall, 16% had clinically significant wasting (weight-for-length Z-score (WHZ) less than - 2) and 20% had stunting (height-for-age Z-score (HAZ) less than - 2). There was no significant association between wasting or stunting and introduction of water before 3 months (WHZ: odds ratio = 0.99, 95% confidence interval 0.46-2.14, P = 0.97; HAZ: 0.68, 0.34-1.36, P = 0.3) or introduction of CFs before 6 months (WHZ: 0.81, 0.46-1.42, P = 0.5; HAZ: 0.79, 0.46-1.35, P = 0.4). A significant association was found between wasting and male sex, age, living in Guede community, drinking river/pond water and large family size, while stunting was associated with age and drinking tap water. CONCLUSION: The results of the present study suggest that early introduction of water and CFs is frequent and is not associated with increased risk for malnutrition among children from this region of northern Senegal, but the possibility of reverse causality cannot be excluded.     

Nutritional status of the Andean population of Puna and Quebrada of Humahuaca, Jujuy, Argentina

OBJECTIVE: To assess the nutritional status of the Andean population of Puna and Quebrada of Humahuaca, Jujuy, using anthropometric measurements. DESIGN AND SUBJECTS: A cross-sectional nutritional survey was carried out in a representative sample (n = 1236) of individuals from these regions. Children aged 2-9 years, adolescents (10-17 years) and adults (>or=18 years; pregnant and lactating women excluded) were considered. Height-for-age, weight-for-height and body mass index (BMI) were calculated in children and adolescents and compared with World Health Organization/National Center for Health Statistics/Centers for Disease Control and Prevention reference standards using Z-scores or percentiles, in order to assess the prevalence of stunting, wasting/thinness and excess weight. In adults, BMI, waist circumference (WC) and waist-to-hip (WHR) ratio were used to identify obesity and central adiposity. RESULTS: Stunting (height-for-age Z-score <-2 standard deviations) and obesity (BMI >or= 95th percentile) were found to be major nutritional problems in children and adolescents. Stunting was prevalent in 10.7% of children and 12.4% of adolescents; 8.2% of children and 3.5% of adolescents were obese. Adults were short (mean: 155.8 cm) and values of overweight (32.3%), obesity (18.3%) and central adiposity (mean WC: 86.5 cm) were high. Older adults and those with higher economic development showed higher prevalence of obesity and central adiposity. CONCLUSIONS: The present population may be at the early stages of nutritional transition as symptoms of undernutrition and overnutrition coexist at the population level. These results suggest that rates of growth retardation may be decreasing owing to improved nutritional conditions; however, this could be accompanied by a sharp increase in the prevalence of other diet-related chronic diseases.     

Predictors of poor anthropometric status among children under 2 years of age in rural Uganda

OBJECTIVE: To assess predictors of poor anthropometric status among infants and young children.DESIGN: Cross-sectional survey.SETTING: The rural subsistence agricultural district of Hoima, western Uganda.SUBJECTS: Seven hundred and twenty children aged 0-23 months with their mothers/carers.METHODS: Participants were recruited in September 2002, using a two-stage cluster sampling methodology. A structured questionnaire was administered to mothers in their home settings. Information on health, household socio-economic status, child feeding practices and anthropometric measurement was gathered. Conditional logistic regression analysis was applied taking into account the hierarchical relationships between potential determinants of poor anthropometric status.RESULTS: The mean Z-score for weight-for-height was -0.2 (95% confidence interval (CI) -0.1, -0.7), for height-for-age was -1.1 (95% CI -1.2, -0.9) and for weight-for-age was -0.7 (95% CI -0.8, -0.6). Wasting was independently associated only with a history of fever in the 2 weeks prior to the survey (odds ratio (OR)=4.4, 95% CI 1.5, 13), while underweight was associated with a history of fever (OR=2.4, 95% CI 1.3, 4.4) and cough (OR=3.0, 95% CI 1.3, 6.8). Stunting was positively associated with a wider range of factors, including: history of a fever episode (OR=1.7, 95% CI 1.0, 2.9), lack of a latrine in the household (OR=2.7, 95% CI 1.5, 4.9), failure to de-worm children 12 months or older (OR=1.7, 95% CI 1.1, 2.8), and being born to a non-formally educated mother compared with mothers educated above primary school (OR=2.1, 95% CI 1.1, 4.0).CONCLUSIONS: In analyses guided by the hierarchical interrelationships of potential determinants of malnutrition, wasting and underweight turned out to be independently predicted by morbidity (proximal) factors. Stunting, however, was predicted by socio-economic (distal), environmental and health-care (intermediate) factors in addition to morbidity. Strategies aimed at improving the growth of infants and young children in rural communities should address morbidity due to common childhood illness coupled with environmental and socio-economically oriented measures.     

Habitual physical activity and body composition of black township adolescents residing in the North West Province, South Africa

OBJECTIVE: It is known that stunting and obesity affect a large proportion of children in the world, and these can be affected by the physical activity levels of the children. In the present study, we evaluated the association between physical activity, physical development and body composition in black adolescent children. DESIGN: Cross-sectional study. SETTING: Black township schools in the North West Province, South Africa. METHODS: Three-hundred and thirteen grade 8 children were included in the Physical Activity in Youth study. Anthropometric measurements, body composition measures and maturity level as assessed by Tanner stages were determined in these children. In addition, Previous Day Physical Activity Recall questionnaires were administered on the children to record the various activities they undertake daily. RESULTS: The demographic characteristics of the children showed a high level of homogeneity. A high prevalence of stunting (16.3%) was observed in the children, which was higher in boys than in girls (21.6 vs. 12.3%). Also prevalent was overweight/obesity (8.6%), but this was higher in girls than in boys (13.4 vs. 1.6%). The children also showed a reduction in levels of physical activity with advancement in maturity; furthermore, boys showed a more central form of fat deposition whilst girls showed more gynoid deposition. CONCLUSIONS: The study revealed that physical activity plays a role in determining body composition, and further indicated that physical activity is associated with favourable body composition measures. Children who were more active were likely to have less fat deposits.     

Parallel deficits in linear growth and mental development in low-income Mexican infants in the second year of life

OBJECTIVE: To explore anthropometric indicators and mental development in very-low-income children in the second year of life. DESIGN: Cross-sectional survey. SETTING: Low-income areas (income <20th percentile) in semi-urban Mexico (defined as towns or cities with 2,500-50,000 inhabitants). SUBJECTS: Eight hundred and ninety-six children aged 12.5-23.5 months surveyed from September to December 2001. METHODS: Questionnaire survey and anthropometric survey of households. Multivariate regression models evaluated differences across age in anthropometry (height-for-age Z-score (HAZ) and weight-for-height Z-score) and cognitive function (Mental Development Index (MDI) of the Bayley Scales of Infant Development) while controlling for socio-economic and parental characteristics. RESULTS: There was a significant decline in HAZ and in age-adjusted MDI score across the second year of life. Although the children showed MDI scores close to the mean, normed US values at 13-14 months, the scores were significantly lower than expected in older children (P < 0.0001), even after controlling for socio-economic status and parental characteristics. At 13-14 months, only 3% of children received scores below 70 (less than minus two standard deviations), whereas by 19-20 months, almost 17% of children were performing below this level. No socio-economic or parental characteristics were significant predictors of HAZ or MDI. CONCLUSIONS: Parallel deficits are evident in both height-for-age and cognitive functioning during the second year of life in low-income Mexican infants. The consistency of these growth and development findings further stresses the need for targeted interventions to reduce the vulnerability of low-income Mexican children very early in life.     

Breakfast eating and overweight in a pre-school population: is there a link?

OBJECTIVES: To analyse the socio-economic factors related to breakfast eating, the association between breakfast eating and overweight, and to gain a more thorough understanding of the relationship between these two elements in a population-based cohort of 4.5-year-old children. We hypothesised that a relationship could be observed between breakfast skipping and overweight independently of socio-economic factors such as ethnicity, maternal education, single parenting and family income. DESIGN: A population-based study whereby standardised nutritional interviews were conducted with each child's parent. The children's height and weight were taken by a trained nutritionist and parents were asked about their child's breakfast eating. SETTING: The analyses were performed using data from the Québec Longitudinal Study of Child Development (1998-2002), conducted by Santé Québec (Canada). SUBJECTS: Subjects were 1549 children between the ages of 44 and 56 months, with a mean age of 49 months. RESULTS: Almost a tenth (9.8%) of the children did not eat breakfast every day. A greater proportion of children with immigrant mothers (19.4% vs. 8.3% from non-immigrant mothers), with mothers with no high school diploma (17.5% vs. <10% for higher educated mothers) and from low-income families (15% for income of $39,999 or less vs. 5-10% for better income) did not eat breakfast every day. Not eating breakfast every day nearly doubled the odds (odds ratio=1.9, 95% confidence interval 1.2-3.2) of being overweight at 4.5 years when mother's immigrant status, household income and number of overweight/obese parents were part of the analysis. CONCLUSION: Although our results require replication before public policy changes can be advocated, encouraging breakfast consumption among pre-school children is probably warranted and targeting families of low socio-economic status could potentially help in the prevention of childhood obesity.     

Nutritional status of Amerindian children from the Beni River (lowland Bolivia) as related to environmental, maternal and dietary factors

OBJECTIVES: To report the nutritional status of children aged up to 15 years and their mothers living in a remote Amazonian area of Bolivia, and to study its main social, familial and maternal determinants.SETTING: Fifteen Beni River communities located at the foot of the Andes.DESIGN: Cross-sectional survey of riverside populations. All childbearing mothers and their children in the 15 communities were examined.METHODS: Information on household production, dietary habits and demography was collected. Individual clinical, anthropometric and parasitological examinations were carried out.SUBJECTS: A total of 631 persons were examined: 171 mothers and 460 children and adolescents aged 0 to 15 years.Results: There were no cases of severe wasting, but 41% of 0-5-year-olds and 36% of 5-10-year-olds were stunted. Among 346 stool specimens examined, 75% were positive for at least one helminth. Diversity of food and quality of diet were satisfactory in 54% of households, but 27% had low diversity scores. Mothers were lighter and shorter than those observed at the national level: 20% had height below 145 cm. Prevalence of anaemia (42%) was also higher. In pre-school children, multivariate analysis indicated a relationship between growth retardation and household factors such as dietary quality, ethnic group and clinical state, but not maternal anthropometry. In contrast, in school-age children and adolescents, growth retardation was related to maternal characteristics.CONCLUSIONS: Growth retardation appeared mainly during the weaning period and did not seem to improve thereafter. To ameliorate this situation, an effort should be made to prevent common parasitic and infectious diseases in young children. Follow-up of pregnant mothers during pregnancy and delivery also needs to be reinforced.     

An evaluation of the impact of a school nutrition programme in Vietnam

OBJECTIVE: To evaluate the effectiveness of a school nutrition programme on the weight gain and growth of Vietnamese schoolchildren. DESIGN: A proximate cluster evaluation of children in seven schools, in which fortified milk and biscuits supplying 300 kcal of energy were being given on school days, compared with children in 14 nearby schools with no feeding. All children were dewormed. SETTING: Twenty-one primary schools in Dong Thap Province, Vietnam. SUBJECTS: A cohort of 1080 children in grade 1 of 21 primary schools, and a cross-sectional interview of 400 children in grade 3. RESULTS: The programme gave children the equivalent of 90 kcal day- 1 over 17 months. t-Tests showed a small but statistically significant difference between groups in their average gain in weight and height: 3.19 versus 2.95 kg (P < 0.001) and 8.15 versus 7.88 cm (P = 0.008). A multiple-level model showed that the programme was statistically significant after controlling for clustering of children in schools, sex, age and initial underweight (P = 0.024). A significant impact on height was also seen in a regression model, but not when controlling for school. The most undernourished children tended to gain the least weight. There was no evidence of substitution. CONCLUSION: The programme had a small but significant effect on weight gain, but the most undernourished children benefited the least. Methods need to be developed to target them. This design may offer a means of estimating the impact of school feeding on growth in other programme settings.     

AIDS, drought, and child malnutrition in southern Africa

OBJECTIVE: To investigate trends in child malnutrition in six countries in southern Africa, in relation to the HIV epidemic and drought in crop years 2001/2 and 2002/3. DESIGN: Epidemiological analysis of sub-national and national surveys with related data.Setting: Data from Lesotho, Malawi, Mozambique, Swaziland, Zambia and Zimbabwe, compiled and analysed under UNICEF auspices. SUBJECTS: Secondary data: children 0-5 years for weight-for-age; HIV prevalence data from various sources especially antenatal clinic surveillance. RESULTS: Child nutritional status as measured by prevalence of underweight deteriorated from 2001 onwards in all countries except Lesotho, with very substantial increases in some provinces/districts (e.g. from 5 to 20% in Maputo (Mozambique, 1997-2002), 17 to 32% in Copperbelt (Zambia, 1999-2001/2) and 11 to 26% in Midlands province (Zimbabwe, 1999-2002)). Greater deterioration in underweight occurred in better-off areas. Areas with higher HIV/AIDS prevalences had (so far) lower malnutrition rates (and infant mortality rates), presumably because more modern areas--with greater reliance on trade and wage employment--have more HIV/AIDS. Areas with higher HIV/AIDS showed more deterioration in child nutrition. A significant area-level interaction was found of HIV/AIDS with the drought period, associated with particularly rapid deterioration in nutritional status. CONCLUSIONS: First, the most vulnerable may be households in more modern areas, nearer towns, to whom resources need to be directed. Second, the causes of this vulnerability need to be investigated. Third, HIV/AIDS amplifies the effect of drought on nutrition, so rapid and effective response will be crucial if drought strikes again. Fourth, expanded nutritional surveillance is now needed to monitor and respond to deteriorating trends. Finally, with or without drought, new means are needed of bringing help, comfort and assistance to the child population.