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INTRODUCTION: Nutrition during the complementary feeding period (6-23 months) is critical to ensure optimal growth and reduce the risk of diet-related disease across the life course. Strategies to reduce multiple forms of malnutrition (stunting, overweight/obesity and anaemia) in infants and young children (IYC) are a key priority in low-income and middle-income countries, including Peru. This study aims to co-design and develop prototypes for interventions to address the multiple forms of malnutrition in IYC in urban Peru, using a participatory design approach. METHODS AND ANALYSIS: The study will be based within peri-urban communities in two areas of Peru (Lima and Huánuco city). Following the identification of key nutritional challenges for IYC aged 6-23 months through formative research (phase I), we will conduct a series of workshops bringing together healthcare professionals from government health centres and caregivers of IYC aged 6-23 months. Workshops (on idea generation; creating future scenarios; storyboarding and early implementation and feedback) will take place in parallel in the two study areas. Through these workshops, we will engage with community participants to explore, experiment, co-design and iteratively validate new design ideas to address the challenges around IYC complementary feeding from phase I. Workshop outputs and transcripts will be analysed qualitatively using affinity diagramming and thematic analyses. The intervention prototypes will be evaluated qualitatively and piloted with the participating communities. ETHICS AND DISSEMINATION: Ethical approval for this study was obtained from the Ethical Review Committee of the Instituto de Investigación Nutricional (IIN) Peru (388-2019/CIEI-IIN), Loughborough University (C19-87) and confirmed by Cardiff University. Findings of the participatory design process will be disseminated through a deliberative workshop in Lima, Peru with national and regional government stakeholders, as well as participants and researchers involved in the design process. Further dissemination will take place through policy briefs, conferences and academic publications.
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Fenômenos Fisiológicos da Nutrição Infantil , Desnutrição , Lactente , Criança , Humanos , Pré-Escolar , Peru , Estado Nutricional , Fenômenos Fisiológicos da Nutrição do LactenteRESUMO
The COVID-19 pandemic may impact diet and nutrition through increased household food insecurity, lack of access to health services, and poorer quality diets. The primary aim of this study is to assess the impact of the pandemic on dietary outcomes of mothers and their infants and young children (IYC) in low-income urban areas of Peru. We conducted a panel study, with one survey prepandemic (n = 244) and one survey 9 months after the onset of COVID-19 (n = 254). We assessed breastfeeding and complementary feeding indicators and maternal dietary diversity in both surveys. During COVID-19, we assessed household food insecurity experience and economic impacts of the pandemic on livelihoods; receipt of financial or food assistance, and uptake of health services. Almost all respondents (98.0%) reported adverse economic impacts due to the pandemic and 46.9% of households were at risk of moderate or severe household food insecurity. The proportion of households receiving government food assistance nearly doubled between the two surveys (36.5%-59.5%). Dietary indicators, however, did not worsen in mothers or IYC. Positive changes included an increase in exclusive breastfeeding <6 months (24.2%-39.0%, p < 0.008) and a decrease in sweet food consumption by IYC (33.1%-18.1%, p = 0.001) and mothers (34.0%-14.6%, p < 0.001). The prevalence of sugar-sweetened beverage consumption remained high in both mothers (97%) and IYC (78%). In sum, we found dietary indicators had not significantly worsened 9 months into the COVID-19 pandemic. However, several indicators remain suboptimal and should be targeted in future interventions.
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COVID-19 , Mães , COVID-19/epidemiologia , Criança , Pré-Escolar , Dieta , Feminino , Insegurança Alimentar , Abastecimento de Alimentos , Humanos , Lactente , Pandemias , Peru/epidemiologia , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Adrenarche involves maturation of the hypothalamic-pituitary-adrenal axis and increased production of dehydroepiandrosterone and its sulfate ester, dehydroepiandrosterone-sulfate (DHEA-S). It occurs at ages 6 to 8 in industrialized populations, marking the transition from childhood to juvenility and cognitive development at middle childhood. Studies in subsistence level populations indicate a later age (8-9) for adrenarche, but only two such studies currently exist for comparison. AIMS: To investigate adrenarcheal age among Maya girls and its association with body composition and dietary variables. We hypothesized adrenarche would occur earlier given the current dual burden of nutrition in Mexico. MATERIALS AND METHODS: 25 Maya girls aged 7 to 9 from Merida, Mexico using ELISAs to measure salivary DHEA-S, standard anthropometry for height, weight, and skinfolds, bioelectrical impedance for body composition variables, as well as a food frequency questionnaire for dietary information. RESULTS: Our hypothesis was rejected-adrenarche occurred close to 9 years. While no measures of body composition were significantly associated with adrenarcheal status, girls eating meat and dairy products more frequently had significantly higher DHEA-S levels. DISCUSSION: Like other populations living in ecologically challenging environments, adrenarche occurred relatively late among Maya girls. Adrenarche has been linked to measures of body composition, particularly, the adiposity or body mass index rebound, but no relevant anthropometric measures were associated, possibly because of the small sample. CONCLUSION: Further studies are required to illuminate how adrenarcheal variation relates to developmental plasticity, body composition, pubertal progression, and animal product consumption in other transitional populations.
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Adrenarca/fisiologia , Composição Corporal , Dieta , Estado Nutricional , Adrenarca/etnologia , Criança , Feminino , Humanos , MéxicoRESUMO
BACKGROUND: Nutritional interventions to prevent stunting of infants and young children are most often applied in rural areas in low- and middle-income countries (LMIC). Few interventions are focused on urban slums. The literature needs a systematic assessment, as infants and children living in slums are at high risk of stunting. Urban slums are complex environments in terms of biological, social, and political variables and the outcomes of nutritional interventions need to be assessed in relation to these variables. For the purposes of this review, we followed the UN-Habitat 2004 definitions for low-income informal settlements or slums as lacking one or more indicators of basic services or infrastructure. OBJECTIVES: To assess the impact of nutritional interventions to reduce stunting in infants and children under five years old in urban slums from LMIC and the effect of nutritional interventions on other nutritional (wasting and underweight) and non-nutritional outcomes (socioeconomic, health and developmental) in addition to stunting. SEARCH METHODS: The review used a sensitive search strategy of electronic databases, bibliographies of articles, conference proceedings, websites, grey literature, and contact with experts and authors published from 1990. We searched 32 databases, in English and non-English languages (MEDLINE, CENTRAL, Web of Science, Ovid MEDLINE, etc). We performed the initial literature search from November 2015 to January 2016, and conducted top up searches in March 2017 and in August 2018. SELECTION CRITERIA: Research designs included randomised (including cluster-randomised) trials, quasi-randomised trials, non-randomised controlled trials, controlled before-and-after studies, pre- and postintervention, interrupted time series (ITS), and historically controlled studies among infants and children from LMIC, from birth to 59 months, living in urban slums. The interventions included were nutrition-specific or maternal education. The primary outcomes were length or height expressed in cm or length-for-age (LFA)/height-for-age (HFA) z-scores, and birth weight in grams or presence/absence of low birth weight (LBW). DATA COLLECTION AND ANALYSIS: We screened and then retrieved titles and abstracts as full text if potentially eligible for inclusion. Working independently, one review author screened all titles and abstracts and extracted data on the selected population, intervention, comparison, and outcome parameters and two other authors assessed half each. We calculated mean selection difference (MD) and 95% confidence intervals (CI). We performed intervention-level meta-analyses to estimate pooled measures of effect, or narrative synthesis when meta-analyses were not possible. We used P less than 0.05 to assess statistical significance and intervention outcomes were also considered for their biological/health importance. Where effect sizes were small and statistically insignificant, we concluded there was 'unclear effect'. MAIN RESULTS: The systematic review included 15 studies, of which 14 were randomised controlled trials (RCTs). The interventions took place in recognised slums or poor urban or periurban areas. The study locations were mainly Bangladesh, India, and Peru. The participants included 9261 infants and children and 3664 pregnant women. There were no dietary intervention studies. All the studies identified were nutrient supplementation and educational interventions. The interventions included zinc supplementation in pregnant women (three studies), micronutrient or macronutrient supplementation in children (eight studies), nutrition education for pregnant women (two studies), and nutrition systems strengthening targeting children (two studies) intervention. Six interventions were adapted to the urban context and seven targeted household, community, or 'service delivery' via systems strengthening. The primary review outcomes were available from seven studies for LFA/HFA, four for LBW, and nine for length.The studies had overall high risk of bias for 11 studies and only four RCTs had moderate risk of bias. Overall, the evidence was complex to report, with a wide range of outcome measures reported. Consequently, only eight study findings were reported in meta-analyses and seven in a narrative form. The certainty of evidence was very low to moderate overall. None of the studies reported differential impacts of interventions relevant to equity issues.Zinc supplementation of pregnant women on LBW or length (versus supplementation without zinc or placebo) (three RCTs)There was no evidence of an effect on LBW (MD -36.13 g, 95% CI -83.61 to 11.35), with moderate-certainty evidence, or no evidence of an effect or unclear effect on length with low- to moderate-certainty evidence.Micronutrient or macronutrient supplementation in children (versus no intervention or placebo) (eight RCTs)There was no evidence of an effect or unclear effect of nutrient supplementation of children on HFA for studies in the meta-analysis with low-certainty evidence (MD -0.02, 95% CI -0.06 to 0.02), and inconclusive effect on length for studies reported in a narrative form with very low- to moderate-certainty evidence.Nutrition education for pregnant women (versus standard care or no intervention) (two RCTs)There was a positive impact on LBW of education interventions in pregnant women, with low-certainty evidence (MD 478.44g, 95% CI 423.55 to 533.32).Nutrition systems strengthening interventions targeting children (compared with no intervention, standard care) (one RCT and one controlled before-and-after study)There were inconclusive results on HFA, with very low- to low-certainty evidence, and a positive influence on length at 18 months, with low-certainty evidence. AUTHORS' CONCLUSIONS: All the nutritional interventions reviewed had the potential to decrease stunting, based on evidence from outside of slum contexts; however, there was no evidence of an effect of the interventions included in this review (very low- to moderate-certainty evidence). Challenges linked to urban slum programming (high mobility, lack of social services, and high loss of follow-up) should be taken into account when nutrition-specific interventions are proposed to address LBW and stunting in such environments. More evidence is needed of the effects of multi-sectorial interventions, combining nutrition-specific and sensitive methods and programmes, as well as the effects of 'up-stream' practices and policies of governmental, non-governmental organisations, and the business sector on nutrition-related outcomes such as stunting.
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Países em Desenvolvimento , Transtornos do Crescimento/prevenção & controle , Terapia Nutricional/métodos , Áreas de Pobreza , População Urbana , Bangladesh , Estudos de Casos e Controles , Pré-Escolar , Estudos Controlados Antes e Depois , Dieta Saudável , Suplementos Nutricionais , Humanos , Índia , Lactente , Micronutrientes/administração & dosagem , Mães/educação , Nutrientes/administração & dosagem , Peru , Gestantes , Ensaios Clínicos Controlados Aleatórios como Assunto , Magreza/dietoterapia , Síndrome de Emaciação/dietoterapia , Zinco/administração & dosagemRESUMO
The co-existence of very short stature due to poor chronic environment in early life and obesity is becoming a public health concern in rapidly transitioning populations with high levels of poverty. Individuals who have very short stature seem to be at an increased risk of obesity in times of relative caloric abundance. Increasing evidence shows that an individual is influenced by exposures in previous generations. This study assesses whether maternal poor early life environment predicts her child's adiposity using cross sectional design on Maya schoolchildren aged 7-9 and their mothers (n = 57 pairs). We compared maternal chronic early life environment (stature) with her child's adiposity (body mass index [BMI] z-score, waist circumference z-score, and percentage body fat) using multiple linear regression, controlling for the child's own environmental exposures (household sanitation and maternal parity). The research was performed in the south of Merida, Yucatan, Mexico, a low socioeconomic urban area in an upper middle income country. The Maya mothers were very short, with a mean stature of 147 cm. The children had fairly high adiposity levels, with BMI and waist circumference z-scores above the reference median. Maternal stature did not significantly predict any child adiposity indicator. There does not appear to be an intergenerational component of maternal early life chronic under-nutrition on her child's obesity risk within this free living population living in poverty. These results suggest that the co-existence of very short stature and obesity appears to be primarily due to exposures and experiences within a generation rather than across generations.
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Adiposidade/fisiologia , Estatura/fisiologia , Mães/estatística & dados numéricos , Antropometria , Criança , Estudos Transversais , Feminino , Humanos , Modelos Lineares , México/epidemiologia , Obesidade Infantil , Fatores SocioeconômicosRESUMO
BACKGROUND: Childhood stunting has been associated with an increased risk of obesity in adulthood, but the causes are unclear. This study hypothesizes that stunting significantly reduces both resting and activity energy expenditure. AIM: To assess and describe energy expenditure of low socio-economic Maya children and to determine whether stunting is independently related to energy expenditure after controlling for lean mass. SUBJECTS AND METHODS: Thirty-three urban Maya children, 17 boys, aged 7-9 years, living in Merida, Mexico, were measured for height, weight and bioelectrical impedance analysis (BIA). Body composition was estimated from BIA. Energy expenditure was measured for one week using the Actiheart (combined heart rate and accelerometer). RESULTS: Stunting (height-for-age below the 5(th) percentile of NHANES III based references) affected 35% of these physically active children. Using multiple linear regression analysis, greater lean body mass predicted higher resting and activity energy expenditure. Stature was not a significant predictor of resting energy expenditure. A lower height-for-age z-score, but not stunting as a categorical variable, significantly predicted lower activity energy expenditure. CONCLUSION: The hypothesis that stunting reduces total energy expenditure (resting + active) in children is not supported. Rather, children with shorter stature and less lean body mass have lower total energy expenditure. Complex interactions between body size, body composition, and metabolic activity appear to elevate the risk for later life obesity in these Maya children.
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Distribuição da Gordura Corporal , Metabolismo Energético/fisiologia , Transtornos do Crescimento/fisiopatologia , Obesidade/fisiopatologia , Composição Corporal/fisiologia , Estatura/fisiologia , Criança , Estudos Transversais , Impedância Elétrica , Feminino , Humanos , Modelos Lineares , Masculino , México , População UrbanaRESUMO
This paper focuses on the phenomenon of the nutritional dual-burden in the developing world. Nutritional dual-burden is defined as the coexistence of under-and-over nutrition in the same population/group, the same household/family, or the same person. In this paper we aim: a) to describe the different types of nutritional dual-burden, b) to identify the anthropometric indicators generally used to classify the nutritional dual-burden, c) to focus our attention on a dual-burden group (the Maya from Merida, Yucatan, Mexico), d) to illustrate problems in the categorization of the dual-burden, and e) to suggest possible health implications. Our results show that, for our sample, the prevalence of individual dual-burden among children is very low, but is very high among the mothers and for mother-child pairs (household dual-burden). Most importantly, the criteria used to assess the nutritional status of the individuals and of the families will play an important role in the estimated prevalence of nutritional dual-burden, and this will have practical impacts for health intervention programs.
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Transtornos da Nutrição Infantil/epidemiologia , Países em Desenvolvimento/estatística & dados numéricos , Mães/estatística & dados numéricos , Obesidade/epidemiologia , Antropometria/métodos , Criança , Saúde da Família/estatística & dados numéricos , Nível de Saúde , Humanos , México/epidemiologia , Prevalência , Fatores de RiscoRESUMO
OBJECTIVES: Body mass index (BMI) is used frequently to estimate adiposity levels in children and adults. However, the applicability of BMI to populations with high levels of stunting has been questioned. Stunted people can have disproportionately short legs, which may increase BMI without increasing body fat because of the relatively larger trunk compared with the legs. METHODS: A sample of 57 urban Maya schoolchildren, aged 7-9 years (31 boys), and 53 adult women underwent anthropometric assessments and bioelectrical impedance analysis. Multiple linear regression was performed to determine whether the ability of BMI to predict adiposity indicators is altered by stunting and sitting height ratio (SHR). The adiposity indicators were waist circumference, sum of skinfolds, upper arm muscle area, upper arm fat area, and arm fat index. RESULTS: BMI was the strongest predictor of all adiposity indicators and in most cases, explained more of the variance in adiposity of Maya children than Maya women. Abdominal adiposity was better predicted by BMI than peripheral adiposity in Maya women and Maya children. Stunting was significant in predicting adiposity in some models but never substantially changed the variance explained. SHR was never a significant predictor. CONCLUSIONS: The relationship between BMI and adiposity indicators is not changed by stunting status or body proportions in this short population of urban Maya children and women. BMI can be used as an indicator of adiposity for these children but not the women. It is recommended that BMI is used in conjunction with other estimates of body composition.
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Adiposidade , Antropometria/métodos , Índice de Massa Corporal , Transtornos do Crescimento/complicações , Obesidade/diagnóstico , Adulto , Composição Corporal , Estatura , Criança , Feminino , Humanos , Masculino , México , Obesidade/complicações , População UrbanaRESUMO
Logistics of using new measurement devices are important to understand when developing protocols. This paper discusses the logistics of using Actiheart physical activity monitors on children in an urban, tropical environment in a developing country. Actiheart monitoring of 36 children aged 7-9 years old was undertaken for 7 days in the city of Mérida, Yucatán, Mexico. The Actiheart proved fragile for children and difficult to mend in the field. The excessive sweating due to the tropical climate caused poor adherence of the electrode pads, requiring a pad change midway through and extra pads to be provided. Also extra time was needed to be allotted for increased instructions to participants and their mothers and for individual calibration. When collecting objectively measured physical activity data under harsh conditions, the protocol must accommodate local conditions and device limitations and allow increased time with participants to obtain good quality data.