REVIEW URRENT C OPINION
Transition of maternal and child nutrition in Asia: implications for public health Pattanee Winichagoon
Purpose of review This article reviews the maternal and child nutrition situation in Asia in transition and its public health implications. Recent findings Countries in Asia are facing a double burden of malnutrition. Accessibility to high energy, less nutrientdense foods or processed foods affects current dietary patterns, whereas industrialization is leading to more sedentary lifestyles both in rural and urban areas. Stunting and wasting among young children persist but have declined in severity, whereas overweight and obesity have risen rapidly. Growth faltering in height during the first 2 years of life has affected muscle mass accretion, but rapid weight gain after 2 years of age has led to more fat accretion, imposing risks of childhood obesity and consequent metabolic disorders. The number of women entering pregnancy with low BMI has decreased, but increasing BMI is noticeable. Prepregnancy BMI and gestational weight gain are important determinants of maternal nutrition during pregnancy, the risk of gestational diabetes and postpartum weight retention, as well as obesity and diet-related noncommunicable diseases in later adulthood. Summary Asia in transition is faced with persistent undernutrition and increasing trends of obesity and metabolic disorders among children and women. The first 1000 days from conception is a critical period, but it is also a window of opportunity for preventing double burden of malnutrition in Asian countries characterized by a nutrition transition. Keywords Asia, maternal and child, nutrition, transition
INTRODUCTION The Lancet series on maternal and child nutrition advocated the significance of the ‘critical 1000 days’, the life-course approach and scaling-up of nutrition-specific and nutrition-sensitive interventions [1 ]. Mason et al. [2 ] further added that for low and middle-income countries (LMICs), the most critical period is probably narrower, that is, within the first 500 days, which includes maternal nutrition during pregnancy through the first 6 months of life. Global efforts during the past couple of decades have contributed to reducing maternal undernutrition in several LMICs in Asia and Africa. However, the steady rise of overnutrition in children and women is outpacing the decline in undernutrition. Rapid development in Asia from traditional agrarian societies to modern, technologically reliant societies has occurred in a relatively short time span. Although development has brought about improvement in infrastructure and basic services (e.g., health and education), it has also led to changes &
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in the living environment, in particular, food availability and accessibility, time allocation in daily life, and changes from labor-intensive to sedentary work, and in leisure activities. These lifestyle changes also have impacted on dietary intakes and physical activity patterns and have brought about a changing nutrition scenario, namely, the ‘nutrition transition’. This article addresses the maternal and child nutrition situation in Asia under this rapid development transition and its implications on public health. The focus of the review is on the low and middle-income Asian countries.
Institute of Nutrition, Mahidol University, Salaya, Thailand Correspondence to Pattanee Winichagoon, Institute of Nutrition, Mahidol University, Phutthamonthon 4 Rd, Salaya, Nakhon Pathom 73170, Thailand. Tel: +66 2 800 2380; fax: +66 2 441 9344; e-mail: [email protected] Curr Opin Clin Nutr Metab Care 2015, 18:312–317 DOI:10.1097/MCO.0000000000000158 Volume 18 Number 3 May 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Transition of maternal and child nutrition in Asia Winichagoon
KEY POINTS With rapid industrialization, Asian countries are facing both under and overnutrition, or the so-called ‘double burden of malnutrition’ (DBMN). Maternal and child nutrition in Asia is moving away from severe micronutrient deficiencies and chronic protein and energy deficits toward increasing trends of obesity and related chronic diseases. Policies and strategic actions are urgently needed to curb the risks imposed by changing dietary patterns and lifestyles, which are most likely related to the increases in obesity and diet-related chronic diseases in children and women, both in rural and urban areas of Asia in transition. The critical period of 1000 days, from conception to 24 months of life, is the window of opportunity for preventing short and long-term consequences on growth, cognitive development, and nutrition-related metabolic disorders.
DOUBLE BURDEN OF MALNUTRITION IN ASIA Asia is the largest and most populated continent in the world with two very large countries, India and China, accounting for over 2 billion people. The overall prevalence of under-five stunting was 26.8%, wasting 10.1%, and overweight 5%. Large discrepancies in the prevalence of maternal and child undernutrition are observed among countries in this region [3]. Low birth weight, stunting, and wasting were three to six times higher in south Asia than south-east Asia/Pacific regions, whereas overweight/obesity was comparable (4–5%). Low birth weight ranged from 3% in China to 28% in India; stunting 10% in China to 58% in Timor-Leste; and wasting 2% in China to 20% in India. On the other hand, overweight/obesity prevalence was only 1% in Sri Lanka but 12% in Indonesia. Using the WHO growth standard [4], Kerac et al. [5] showed that the prevalence of wasting among infants below 6 months of age was much higher than previously reported. Growth faltering began within the first few months after birth in LMIC and faltering in height (height for age, HAZ) was the most dramatic [6]. In south-east Asia, weight-for-age z-score (WAZ) fell by 12 months and tapered off until 4 years of age. The pattern of faltering in height was similar to other regions in terms of timing, but more dramatic. Leroy et al. [7] and Lundeen et al. [8] both demonstrated that while HAZ increased, the cumulative height deficits continued possibly beyond 5 years of age. In south Asia, this height deficit was as high as 8.5 cm compared with 7.5 cm
in Africa and 4.5 cm in other regions [7]. Although the largest urban/rural differences in height were in China and Vietnam, weight differentials were large in east and south-east Asia [9 ,10]. These urban/ rural differences in child growth reflect the unequal distribution of income and social services (healthcare, water, sanitation, and specific infant and young child feeding interventions). Therefore, in examining the situation, HAZ and cumulative height deficit may need to be considered simultaneously. Recent surveys among children in four countries (Indonesia, Malaysia, Thailand, and Vietnam, the south-east Asia nutrition surveys) revealed that micronutrient deficiencies persisted, although the severity was mostly mild to moderate [11–14]. Anemia was still prevalent and complicated by other causes in addition to iron deficiency. In Vietnam and Indonesia where vitamin A supplementation has been a national program, the prevalence of vitamin A deficiency was low; subclinical vitamin A deficiency was present in all surveyed countries. Insufficiency of vitamin D was surprisingly high and its cause needs to be elucidated. Iron deficiency and associated anemia was also observed in overweight and obese individuals [15]. Poor utilization of micronutrients among overweight/obese children and women has been reported [16,17]. In Thailand, an inverse relationship between BMI and iron bioavailability among reproductive-age women was shown. In Indian and Moroccan children, iron status was inversely related to BMI, and responses to iron fortification were less among overweight children. Another study showed that overweight pregnant women had a four-fold higher risk of hypothyroxinemia during the first trimester compared with the normal-weight women [17]. The copresence of micronutrient deficiencies and overnutrition has not been documented from large-scale surveys in LMIC in Asia. &&
Changing patterns of infant and young child feeding Exclusive breastfeeding (EBF) varied widely with a regional average rate of early initiation of breastfeeding at 41% for both east Asia and Pacific and south Asia, whereas EBF prevalence was only 30 and 49%, respectively [3]. High EBF until 6 months was observed in a few countries, namely, Bangladesh (64%), Cambodia (74%), Nepal (70%), and Sri Lanka (76%), although much lower (
Transition of maternal and child nutrition in Asia: implications for public health Pattanee Winichagoon
Purpose of review This article reviews the maternal and child nutrition situation in Asia in transition and its public health implications. Recent findings Countries in Asia are facing a double burden of malnutrition. Accessibility to high energy, less nutrientdense foods or processed foods affects current dietary patterns, whereas industrialization is leading to more sedentary lifestyles both in rural and urban areas. Stunting and wasting among young children persist but have declined in severity, whereas overweight and obesity have risen rapidly. Growth faltering in height during the first 2 years of life has affected muscle mass accretion, but rapid weight gain after 2 years of age has led to more fat accretion, imposing risks of childhood obesity and consequent metabolic disorders. The number of women entering pregnancy with low BMI has decreased, but increasing BMI is noticeable. Prepregnancy BMI and gestational weight gain are important determinants of maternal nutrition during pregnancy, the risk of gestational diabetes and postpartum weight retention, as well as obesity and diet-related noncommunicable diseases in later adulthood. Summary Asia in transition is faced with persistent undernutrition and increasing trends of obesity and metabolic disorders among children and women. The first 1000 days from conception is a critical period, but it is also a window of opportunity for preventing double burden of malnutrition in Asian countries characterized by a nutrition transition. Keywords Asia, maternal and child, nutrition, transition
INTRODUCTION The Lancet series on maternal and child nutrition advocated the significance of the ‘critical 1000 days’, the life-course approach and scaling-up of nutrition-specific and nutrition-sensitive interventions [1 ]. Mason et al. [2 ] further added that for low and middle-income countries (LMICs), the most critical period is probably narrower, that is, within the first 500 days, which includes maternal nutrition during pregnancy through the first 6 months of life. Global efforts during the past couple of decades have contributed to reducing maternal undernutrition in several LMICs in Asia and Africa. However, the steady rise of overnutrition in children and women is outpacing the decline in undernutrition. Rapid development in Asia from traditional agrarian societies to modern, technologically reliant societies has occurred in a relatively short time span. Although development has brought about improvement in infrastructure and basic services (e.g., health and education), it has also led to changes &
&
www.co-clinicalnutrition.com
in the living environment, in particular, food availability and accessibility, time allocation in daily life, and changes from labor-intensive to sedentary work, and in leisure activities. These lifestyle changes also have impacted on dietary intakes and physical activity patterns and have brought about a changing nutrition scenario, namely, the ‘nutrition transition’. This article addresses the maternal and child nutrition situation in Asia under this rapid development transition and its implications on public health. The focus of the review is on the low and middle-income Asian countries.
Institute of Nutrition, Mahidol University, Salaya, Thailand Correspondence to Pattanee Winichagoon, Institute of Nutrition, Mahidol University, Phutthamonthon 4 Rd, Salaya, Nakhon Pathom 73170, Thailand. Tel: +66 2 800 2380; fax: +66 2 441 9344; e-mail: [email protected] Curr Opin Clin Nutr Metab Care 2015, 18:312–317 DOI:10.1097/MCO.0000000000000158 Volume 18 Number 3 May 2015
Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Transition of maternal and child nutrition in Asia Winichagoon
KEY POINTS With rapid industrialization, Asian countries are facing both under and overnutrition, or the so-called ‘double burden of malnutrition’ (DBMN). Maternal and child nutrition in Asia is moving away from severe micronutrient deficiencies and chronic protein and energy deficits toward increasing trends of obesity and related chronic diseases. Policies and strategic actions are urgently needed to curb the risks imposed by changing dietary patterns and lifestyles, which are most likely related to the increases in obesity and diet-related chronic diseases in children and women, both in rural and urban areas of Asia in transition. The critical period of 1000 days, from conception to 24 months of life, is the window of opportunity for preventing short and long-term consequences on growth, cognitive development, and nutrition-related metabolic disorders.
DOUBLE BURDEN OF MALNUTRITION IN ASIA Asia is the largest and most populated continent in the world with two very large countries, India and China, accounting for over 2 billion people. The overall prevalence of under-five stunting was 26.8%, wasting 10.1%, and overweight 5%. Large discrepancies in the prevalence of maternal and child undernutrition are observed among countries in this region [3]. Low birth weight, stunting, and wasting were three to six times higher in south Asia than south-east Asia/Pacific regions, whereas overweight/obesity was comparable (4–5%). Low birth weight ranged from 3% in China to 28% in India; stunting 10% in China to 58% in Timor-Leste; and wasting 2% in China to 20% in India. On the other hand, overweight/obesity prevalence was only 1% in Sri Lanka but 12% in Indonesia. Using the WHO growth standard [4], Kerac et al. [5] showed that the prevalence of wasting among infants below 6 months of age was much higher than previously reported. Growth faltering began within the first few months after birth in LMIC and faltering in height (height for age, HAZ) was the most dramatic [6]. In south-east Asia, weight-for-age z-score (WAZ) fell by 12 months and tapered off until 4 years of age. The pattern of faltering in height was similar to other regions in terms of timing, but more dramatic. Leroy et al. [7] and Lundeen et al. [8] both demonstrated that while HAZ increased, the cumulative height deficits continued possibly beyond 5 years of age. In south Asia, this height deficit was as high as 8.5 cm compared with 7.5 cm
in Africa and 4.5 cm in other regions [7]. Although the largest urban/rural differences in height were in China and Vietnam, weight differentials were large in east and south-east Asia [9 ,10]. These urban/ rural differences in child growth reflect the unequal distribution of income and social services (healthcare, water, sanitation, and specific infant and young child feeding interventions). Therefore, in examining the situation, HAZ and cumulative height deficit may need to be considered simultaneously. Recent surveys among children in four countries (Indonesia, Malaysia, Thailand, and Vietnam, the south-east Asia nutrition surveys) revealed that micronutrient deficiencies persisted, although the severity was mostly mild to moderate [11–14]. Anemia was still prevalent and complicated by other causes in addition to iron deficiency. In Vietnam and Indonesia where vitamin A supplementation has been a national program, the prevalence of vitamin A deficiency was low; subclinical vitamin A deficiency was present in all surveyed countries. Insufficiency of vitamin D was surprisingly high and its cause needs to be elucidated. Iron deficiency and associated anemia was also observed in overweight and obese individuals [15]. Poor utilization of micronutrients among overweight/obese children and women has been reported [16,17]. In Thailand, an inverse relationship between BMI and iron bioavailability among reproductive-age women was shown. In Indian and Moroccan children, iron status was inversely related to BMI, and responses to iron fortification were less among overweight children. Another study showed that overweight pregnant women had a four-fold higher risk of hypothyroxinemia during the first trimester compared with the normal-weight women [17]. The copresence of micronutrient deficiencies and overnutrition has not been documented from large-scale surveys in LMIC in Asia. &&
Changing patterns of infant and young child feeding Exclusive breastfeeding (EBF) varied widely with a regional average rate of early initiation of breastfeeding at 41% for both east Asia and Pacific and south Asia, whereas EBF prevalence was only 30 and 49%, respectively [3]. High EBF until 6 months was observed in a few countries, namely, Bangladesh (64%), Cambodia (74%), Nepal (70%), and Sri Lanka (76%), although much lower (
