Double Trouble: Stunted Children at Higher Risk of Obesity

May 21, 2015

PRAGUE — Children who are stunted are more likely to be at risk of overweight and obesity than children of normal height, according to a new study among 2- to 5-year-olds in Indonesia, the world's fourth most populous nation.

And while the prevalence of stunting is decreasing, it still remains very high, affecting one in three children in Indonesia, Louise Baur, MBBS, PhD, a professor of pediatrics and child health at the Children's Hospital at Westmead, Sydney, Australia, told the attendees here at the recent 2015 European Congress on Obesity, where she presented the research.

And this is happening against a backdrop of a "nutrition transition" in this and many other low- and middle-income emerging-economy countries, she noted. As these nations undergo rapid development and people get wealthier, they stop having to perform as many chores, they get cars, they sit more, and they have access to different kinds of food, including Western convenience foods.

All of which creates a "double burden of malnutrition," which can almost certainly be extrapolated to many countries in Asia and other parts of the world, Dr Baur noted.

"This is the new, really important frontier for dealing with nutrition and obesity. While it's been really recognized that undernutrition is an issue, we're now seeing that obesity is a major issue, too."

One of the key messages from this research for healthcare personnel is that interventions to treat undernutrition in very young children "must emphasize improvements in linear growth rather than gaining weight alone," she stressed.

Stunting must be combated while controlling for excess body weight; some countries have already made the mistake of not doing this and paid the price — for example, Chile, she noted.

Asked to comment, Tim Lobstein, PhD, director of policy at the World Obesity Federation, London, United Kingdom, said: "This is probably the most important paper presented this week in terms of how many children are affected by the problems described — we are talking about millions, and if you include India and the rest of south Asia and China, possibly tens of millions, so it's not the problems we have in Europe, in the thousands.

"We sit in Europe and twiddle around with a few patients in clinics when you've got these millions and millions of children who are going to be doubly burdened and at very high risk of chronic disease in quite early adulthood," he told Medscape Medical News.

And "nobody talks about the commercial aspects of all this, which are the major drivers of these problems," he stressed.

"What these countries do have is a rapidly developing commercial market for complementary foods and inappropriate foods for babies and young children. We as a community need to be aware of our professional responsibilities and pay attention to what's happening in these parts of the world — promotion of junk foods and soft drinks at age 1 year and at 6 months even…foods that are calorie rich but are not going to promote linear growth.

"We have a battle on our hands, and you are bringing our attention to one of the most important issues that the [World Health Organization] WHO and the health community has to face in the next few years," he told Dr Baur following her presentation.

Indonesia: A "Nutrition Transition" Blueprint for the Rest of Asia?

Dr Baur presented the findings on behalf of Dr Cut Novianti Rachmi, an Indonesian general practitioner who led the research as part of her PhD thesis while studying at the University of Sydney on a scholarship from Lembaga Pengelola Dana Pendidikan Indonesia.

This was a cross-sectional study of children aged 2 to 4.9 years, repeated in waves (1993, 1997, 2000, and 2007) and based on the Indonesian Family Life Survey, a nationally representative sampling of households there involving questionnaires and anthropometric measurements. The survey included 13 out of 27 provinces in Indonesia and four of the five main islands there — Java, Sumatra, Kalimantan, and Sulawesi.

They set out to determine temporal trends in stunting, underweight, and overweight in the children — height, weight, and body mass index (BMI) were expressed as Z scores (WHO Child Growth Standards 2006).

A weight-for-age Z score of < 2 was categorized as underweight, a height-for-age Z score < 2 as stunted, and a BMI Z score of >+1, >+2 and > +3 as "at risk," overweight, and obese, respectively.

There were 1385, 1461, 2089, and 2676 children aged 2 to 4.9 years in the four waves, respectively.

The prevalence of stunting decreased from waves 1 to 4, from 50.1% to 35.7%, as did the prevalence of underweight — from 33.8% to 20.9%.

In contrast, the prevalence of at risk/overweight/obesity (BMI Z score > +1) increased from 10.8% to 17.4% (< .01).

Key Finding: Stunted Children More Likely to Be Overweight/Obese

The key finding was that, at all time points, those who were stunted were significantly more likely to be at risk of overweight/obese compared with those of healthy height (odds ratio, 1.35 to 2.28 in the different waves; < .05).

And interestingly, in Indonesia — as in other emerging market economies — the researchers saw the reverse of what is observed in Western countries: "Obesity is more common in the urban vs the rural population [in Indonesia]; there's a reverse here, the poorer people in low- and middle-income countries are relatively protected against obesity [in rural areas] until you go through that 'nutrition transition' — that's what our data at this moment would suggest, anyway," Dr Baur explained.

What the scientists are also seeing in Indonesia and elsewhere — including the Middle East, which Dr Baur noted has a huge childhood-obesity problem — is that the trajectory is much steeper than was seen with the childhood-obesity epidemic in the United States and Europe.

The backdrop of stunting may go some way toward explaining this difference, she added. "What we see from this research is that stunting is the bad thing — stunted kids are more likely to be overweight and obese," she reiterated.

Dr Rachmi told Medscape Medical News in an email that stunting is a reflection of nutritional and economic differences — within any one country, more socially advantaged people are taller than those who are socially disadvantaged.

"With few exceptions, we should expect people from different countries to have similar average heights," she observed, citing 2006 WHO Child Growth standards.

These standards demonstrated, for the first time ever, that children born in different regions of the world and given an optimum start in life "have the potential to grow and develop to within the same range of height and weight for age," she explained.

It is not yet known why stunted children are at greater risk of overweight and obesity, but stunting is "a very complex process," she noted, with one possible proposed mechanism for the link being impaired fat oxidation.

Important Implications for Policy Implementation

Dr Baur told Medscape Medical News: "Our study is the first in this age group to show [that stunting and obesity are coexisting], at the individual level."

"The Indonesian government is starting to see it but is still focused on undernutrition as being an issue.…[Meanwhile,] the implications for type 2 diabetes and cardiovascular risk are huge," she stressed.

Both Dr Baur and Dr Rachmi stressed that there are several incredibly important clinical and policy implications of their work that need to be emphasized in Indonesia and in many other emerging economies across Asia and in other parts of the world.

These include the promotion of exclusive breastfeeding, making high-micronutrient-content complementary foods available and accessible to people, and educating parents about the quality of food preferences in later life and the necessity to form a habit of physical activity at an early age.

Also key is the control of infection by improving sanitation and the provision of clean drinking water and improving access to healthcare services, Dr Baur said.

There is still a long way to go in Indonesia in many regards, she said — "the vast majority of children included in this study didn't have their birth weight measured," for example, she noted. And "there aren't dieticians; nurses are overwhelmed.…We're very dependent on good staff in these regions, but it's a very different healthcare system."

However there is hope, said Dr Rachmi, in the form of the fledgling universal healthcare system adopted by Indonesia starting in January 2014.

"Although it is relatively new and not everyone knows his or her rights or how to use the insurance system properly…we are getting there," she told Medscape Medical News.

And in terms of strategies that are in place to help prevent stunting, she said that Indonesia has been dealing with the problem of undernutrition for decades.

"For example, we have an integrated healthcare post (Posyandu) that monitors the health of mothers and young children (including giving them additional and nutritious food) and that provides immunization services."

Although there is undoubtedly much room for improvement, "we have seen declining numbers of undernutrition in Indonesia, and we are hoping that rates will decline more quickly now that we have the [new healthcare] system in place," she observed.

Equally, "the rate of breastfeeding throughout Indonesia is increasing, although it is not as high as many other countries," Dr Rachmi added. "We have support groups everywhere, and we have training programs in place for anyone who wants to become a counselor in lactation.

"However, many working mothers still find breastfeeding a burden instead of 'a natural thing to do.' I think Indonesia has enough policies…to make breastfeeding successful; the problem lies in the implementation of the policies," she observed.

Healthcare Professionals Need to Play Their Part

Dr Rachmi also stressed the enduring problem of parents "and even healthcare professionals" tending to monitor a child's weight but not height.

"They are very satisfied to hear if their baby is gaining more kilograms — it is very rare for parents to know about the height of their children."

And of course, the influence of marketing of convenience foods is ubiquitous, as in other nations, she commented.

"I think the children in Indonesia — as in many other countries — are almost addicted to junk food. You rarely see under-5 children eating carrots or broccoli in Indonesia.…They eat savory snacks like chips and instant noodles as part of their daily and 'normal' diet."

And "soda and juices are replacing water everywhere," she observed. "I know there are many people who eat well, but…for some people it's easier if they just provide their children with KFC and McDonald's on a daily basis.

"I think people have just started to realize the importance of nutrition recently," she added, acknowledging that, as in most other countries, this will be an uphill battle.

Dr Baur noted that she is on a WHO committee that is looking at the marketing of foods in the first few years of life, "as this is such an issue in low- and middle-income countries in Asia [and beyond] because of the rapid nutrition transition that's occurring; it's really enormous."

And Dr Lobstein believes "there is still some more 'synthesis' to be done between the underweight and overweight categories. Even within WHO,the noncommunicable-diseases department and the nutrition department don't necessarily talk to each other that much."

Development agencies such as Oxfam and War on Want — "all those sorts of groups — are still a little bit focused on the undernutrition; they don't recognize an overnutrition problem as being integral to this," he observed.

Dr Rachmi is hoping her research, some of which she plans to publish soon in an Indonesian journal, will help to illustrate this double burden of malnutrition to some of the influential people in Indonesia.

"UNICEF Indonesia has promised to help with the dissemination of my results, especially to the government of Indonesia. We will also be specifically targeting colleagues in WHO and other such organizations," she said.

"We have the policies, we have the manpower, we have the system in place, but the implementation is weak. We need to encourage everyone, including healthcare workers, to start living healthy active lives."

None of speakers reported any relevant financial relationships.

2015 European Congress on Obesity. May 7, 2015. Abstract T5:OS1.6.

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