Childhood obesity in low- and middle-income countries.

Overweight and obesity in childhood is an increasing problem for the less affluent countries of the world. The prevalence of overweight/obesity varies, not only between countries but across countries, depending on the environments in which children live. Changes in physical activity and diet are having adverse effects on children's nutrition. Greater affluence and urbanisation with more technology such as television in homes are associated with overweight. Affluence also brings the ability to purchase commercial, prepared 'fast-food' items, leading too often to disadvantageous effects on children's diets. The solutions to this rising tide of overweight/obesity seem to lie with broad-based programmes initiated at central government level or at more local community level but which are designed to reach across and throughout societies to enable families and communities to modify the unhealthy lifestyle which too often accompanies increasing affluence and development.

Complementary feeding and non communicable diseases: current knowledge and future research needs.

Early diet and nutrition may set in place growth patterns and/or metabolic pathways that promote risk factors for later NCDs. Most relevant studies so far available have a cross-sectional or retrospective design and are thus of limited validity for evaluating the impact of early feeding on later disease. Standardised protocols for prospective research should be developed. The contribution of protein intake in early life to later NCD development has been the object of several studies; however future research should specifically target the effects of early protein intake on (a) how protein intake influences body composition, (b) how different body composition in infancy contributes to later NCDs, (c) whether there is an age 'window' when high protein intake is particularly associated with later overweight and obesity, (d) what levels of protein intake may protect against later overweight/obesity, (e) what level of cow milk intake in the first years of life minimises risk-inducing growth whilst meeting recommended calcium intakes. The role of the quality of fat and carbohydrate intakes at early ages should be better investigated. There is a dearth of data from many communities about the foods introduced as complementary feeds, the ages at which they are introduced and why mothers use these foods. Definitely more information is needed on how and to what extent mothers' behaviour is influenced by media, advertising and other commercial pressures and why formula fed infants are started on other foods much earlier than breast fed infants. Standardized protocols are needed to develop more data on complementary feeding in different regions, different countries and different socio-economic environments.

Countries in transition: underweight to obesity non-stop?

The rise in childhood overweight and obesity in less developed countries and those with transitional economies is widely recorded. In many cases, this increase in overweight is occurring in societies where levels of under-nutrition remain high. Overweight particularly affects children in affluent families and urban families and is usually much less in rural areas. Changes such as the availability of more Western-style foods, the prevalence of snacking, a decline in physical activity, less sleep and the inactivity associated with watching television may all be contributing to the rise of overweight. The complications of overweight/obesity are already being seen in some affected children. Efforts to treat and prevent overweight in children are needed urgently if the appalling levels of overweight currently seen in the well established market economies of Europe and North America are to be avoided by less developed and transitional economies.

Glucose, insulin and lipid metabolism in rural Gambians exposed to early malnutrition.

AIMS: There is now substantial evidence to suggest that susceptibility to certain non-communicable diseases may be increased by early undernutrition. In rural Gambia, an annual hungry season reduces birth weight by 200-300 g and increases the prevalence of low birth weight (< 2500 g) from 11% to 24%. The aim of this study was to investigate whether fetal nutritional stress (using season of birth as a proxy measure for prenatal growth retardation) or early childhood malnutrition (using historical anthropometric records) had a residual influence on risk factors for cardiovascular disease in a cohort of rural Gambian adults. METHODS: Two hundred and nineteen adults (mean age = 35.8 years; mean body mass index = 21.3 kg/m2; women = 181) for whom month of birth and infant anthropometric records were available participated in this study. Risk factors for cardiovascular disease were measured. RESULTS: No differences were found between season of birth groups (hungry vs. harvest) and fasting measures of glucose, insulin, lipids, fibrinogen or cortisol, or against 30 and 120 min glucose and insulin levels following an oral glucose tolerance test, or blood pressure. Similarly, these risk factors for adult disease were not related to the subjects' weight-for-age as children. CONCLUSIONS: Moderate-to-severe fetal and childhood malnutrition in rural Gambia caused no detectable impairment of the glucose/insulin axis, or of other cardiovascular disease risk factors in adults remaining lean and fit on a low-fat diet.

Effect of calcium supplementation on bone mineral accretion in gambian children accustomed to a low-calcium diet.

BACKGROUND: Rural Gambian children have poor growth, delayed puberty, a low bone mineral content, and a low calcium intake. OBJECTIVE: We investigated the effect of a calcium supplement on bone mineral accretion in rural Gambian children. DESIGN: A randomized, double-blind, placebo-controlled study was conducted in 160 children (80 boys, 80 girls) aged 8.3-11.9 y. Bone mineral content (BMC), bone mineral density (BMD), and BMC adjusted for bone width, body weight, and height (size-adjusted BMC) were measured at the midshaft and distal radius. Each child received either 1000 mg Ca/d (as calcium carbonate) or a placebo 5 d/wk for 12 mo. Supplementation increased calcium intake from 342 to 1056 mg/d (8.6 to 26.4 mmol/d). RESULTS: Calcium supplementation resulted in a higher BMC, BMD, and size-adjusted BMC (&xmacr; difference +/- SE): midshaft radius-BMC (3.0 +/- 1.4%; P = 0.034), BMD (4.5 +/- 0.9%; P

Less diarrhoea but no change in growth: 15 years' data from three Gambian villages.

AIMS: To review diarrhoea presentations and nutritional status in young rural Gambian children over a 15 year period as a test of an earlier hypothesis that reduced diarrhoea prevalence would lead to improved growth and a reduced prevalence of malnutrition. SUBJECTS AND METHODS: Growth and morbidity were documented routinely in 1190 children under 2 years of age attending the Dunn Nutrition Group clinic at Keneba between 1979 and 1993. RESULTS: The numbers of presentations with diarrhoea (1069 in 1979; 220 in 1993) and the proportion of clinic attendees with diarrhoea (30% in 1979; 8% in 1993) fell steadily between 1979 and 1993. However, at both 1 year old, mean weights (Z scores: 1979, -1.8; 1993, -1.8) and mean lengths (Z scores: 1979, -1.3; 1993, -1.7), and at 2 years old, mean weights (Z scores: 1979, -2.0; 1993, -1.9) and mean lengths (Z scores: 1979, -2.0; 1993, -2.1) did not change noticeably over the 15 year period. CONCLUSION: Major progressive reductions in clinic presentations with diarrhoea have not been associated with improved nutritional status in this population of young rural Gambian children.

Prenatal or early postnatal events predict infectious deaths in young adulthood in rural Africa.

BACKGROUND: Research over the past decade has suggested that prenatal and early postnatal nutrition influence the risk of developing chronic degenerative diseases up to 60 years later. We now present evidence that risk of death from infectious diseases in young adulthood is similarly programmed by early life events. METHODS: In three rural Gambian villages, affected by a marked annual seasonality in diet and disease, we have kept detailed demographic, anthropometric and health records since 1949. Fate was known with certainty for 3,162 individuals (2,059 alive/1,103 dead, most dying in childhood). For this case-control analysis of antecedent predictors of premature mortality, all adult deaths (n = 61) were paired with two randomly selected controls matched for sex and year of birth. RESULTS: Mean age at death was 25 (SD: 8) years. Adult death was associated with a profound bias in month of birth with 49 cases born in the nutritionally-debilitating hungry season (Jul-Dec) versus 12 in the harvest season (Jan-Jun). Relative to harvest season the hazard ratio for early death in hungry-season births rose from 3.7 (for deaths >14.5 years, P = 0.000013) to 10.3 (for deaths >25 years, P = 0.00002). Anthropometric and haematological status at 18 months of age was identical in cases and controls, indicating an earlier origin to the defect. Most deaths for which cause was known had a definite or possible infectious aetiology; none were from degenerative diseases of affluence. CONCLUSIONS: Early life exposures, correlated with season of birth, strongly influence susceptibility to fatal infections in young adulthood. The evidence suggests that nutritionally-mediated intrauterine growth retardation may permanently impair the development of immune function.

PIP: This paper presents the influence of prenatal and early postnatal nutrition on the risk of developing chronic degenerative diseases during late adulthood. Investigation of the thrifty phenotype hypothesis using 1949 birth records in three rural Gambian villages illustrates the severity of seasonality in diet and disease patterns. A database of 3162 individuals--2059 survivors and 1103 fatalities--was examined. Using a case-control analysis of antecedent predictors of premature mortality, all deaths were paired with two randomly selected controls matched for sex and year. Results revealed that the mean age at death was 25 years, with 49 adult death cases occurring in the nutritionally debilitating hungry season compared to 12 cases occurring during the harvest season. In relation to the harvest season, the hazard ratio rose from 3.7 (for deaths at age 14.5 years; p = 0.000013) to 10.3 (for deaths at age 25 years; p = 0.00002). Both the anthropometric and hematological status at 18 months was similar in cases and controls, with most deaths caused by a definite or possible infectious etiology without evidence of degenerative disease cause. This study concludes that early life exposures correlated with season of birth significantly influence the susceptibility to fatal infections in young adulthood. This also suggests that nutritionally mediated intrauterine growth retardation could permanently impair the development of immune function.

Effects on birth weight and perinatal mortality of maternal dietary supplements in rural Gambia: 5 year randomised controlled trial .

OBJECTIVE: To test the efficacy in terms of birth weight and infant survival of a diet supplement programme in pregnant African women through a primary healthcare system. DESIGN: 5 year controlled trial of all pregnant women in 28 villages randomised to daily supplementation with high energy groundnut biscuits (4.3 MJ/day) for about 20 weeks before delivery (intervention) or after delivery (control). SETTING: Rural Gambia. SUBJECTS: Chronically undernourished women (twin bearers excluded), yielding 2047 singleton live births and 35 stillbirths. MAIN OUTCOME MEASURES: Birth weight; prevalence of low birth weight (< 2500 g); head circumference; birth length; gestational age; prevalence of stillbirths; neonatal and postneonatal mortality. RESULTS: Supplementation increased weight gain in pregnancy and significantly increased birth weight, particularly during the nutritionally debilitating hungry season (June to October). Weight gain increased by 201 g (P < 0.001) in the hungry season, by 94 g (P < 0.01) in the harvest season (November to May), and by 136 g (P < 0.001) over the whole year. The odds ratio for low birthweight babies in supplemented women was 0.61 (95% confidence interval 0.47 to 0.79, P < 0.001). Head circumference was significantly increased (P < 0.01), but by only 3.1 mm. Birth length and duration of gestation were not affected. Supplementation significantly reduced perinatal mortality: the odds ratio was 0.47 (0.23 to 0.99, P < 0.05) for stillbirths and 0.54 (0.35 to 0.85, P < 0.01) for all deaths in first week of life. Mortality after 7 days was unaffected. CONCLUSION: Prenatal dietary supplementation reduced retardation in intrauterine growth when effectively targeted at genuinely at-risk mothers. This was associated with a substantial reduction in the prevalence of stillbirths and in early neonatal mortality. The intervention can be successfully delivered through a primary healthcare system.

The effects of high-energy feeding on energy balance and growth in infants with congenital heart disease and failure to thrive.

Failure to thrive (FTT) in infants with congenital heart disease (CHD) can be attributed to their low energy intakes and high resting energy expenditures. Energy intake, energy expenditure and growth were studied in infants with CHD on normal formula feeds and then on feeds supplemented with glucose polymer to see whether supplementation improved energy retention and growth. Mean gross energy intakes increased by 31.7% on high-energy feeding and mean weight gain improved from 1.3 g/kg per d on control to 5.8 g/kg per d on high-energy feeding. Resting oxygen consumption (VO2 ml/kg per min) was not significantly different on the two feeding regimens, although respiratory quotient rose on high-energy feeding reflecting the increased carbohydrate intake. Estimated energy costs of growth on high-energy feeding fell within the previously described range for normal infants. It is recommended that infants with CHD known to be associated with FTT are fed on high-energy diets from the time of diagnosis in order to optimize growth.