Nutritional status of children aged 0.5 to 12 years in Indonesia, Malaysia, Thailand and Vietnam: South East Asia Nutrition Survey (SEANUTS) results

Double burden of malnutrition is defined as the persistence of undernutrition and the rapid rise in overweight and obesity. The usual pattern of malnutrition was undernutrition being more prevalent in developing countries while obesity was a common occurrence in developed countries. However, with rapid urbanization, unlimited food access, and lifestyle changes, a trend towards increasing incidence of overweight and obesity has been observed in developing countries.1

In 2011, the United Nations (UN) estimated that more than 165 million children under 5 years old were stunted, 100 million children were underweight and around 52 million were wasted. Unfortunately, some of the highest prevalence of malnutrition was seen in Asia, particularly in the south-central region.2 The prevalence of overweight in Asia was recorded at 5%, affecting an estimated 17 million children. Among school-aged children, reported median prevalence of overweight and obesity are 16% and 8%, respectively. But despite these figures, the burden of overweight and obesity in SEA is generally below the median.2-3

The SEANUTS is a multicenter, cross-sectional study which aimed to evaluate the nutritional status of representative samples of children aged 0.5 to 12.9 years in Indonesia, Malaysia, Thailand and Vietnam. Data pertinent to determining the nutritional status of the subjects included among others anthropometric parameters, nutritional intake and food habits, and blood chemistry.4-7

Height and weight are the most commonly used anthropometric measures to assess adequate growth of a child or a group of children. Height-for-age reflects linear growth and can measure stunting. Weight-for-age represents a synthesis of both linear growth and body proportion and can be used to diagnose underweight children. On the other hand, body mass index-for-age is a useful screening tool for thinness, overweight and obesity.8

In SEANUTS, height-for-age z-scores (HAZ), weight-for-age z-scores (WAZ) and body mass index-for-age z-scores (BAZ) were correlated with World Health Organization (WHO) growth standards for 0-5 years and the WHO growth reference for 5-19 years. The cut-off value for stunting and thinness was -2 SD. For children <5 years to be classified as overweight and obese, the cut-off value used was 2 SD; for older children, it was 1 SD and 2 SD, respectively.4-8

Results of the SEANUTS study showed that stunting was a major nutritional problem in Indonesia (25%, urban; 39%, rural) compared to Malaysia (8.3%, urban; 8.8% rural), Thailand (4.1%, urban; 8.4%, rural) and Vietnam (7.9%, urban; 17.5%, rural). In Indonesia, Thailand, and Vietnam, it was noted that stunting, thinness and underweight were more common in rural areas. Overweight and obesity were higher among urban children in all countries (32.8%, Vietnam; 22.4%, Malaysia; 18.7%, Thailand and 10.7%, Indonesia) compared to those in the rural setting (7.5%, Vietnam; 18.1%, Malaysia; 13.9%, Thailand and 5%, Indonesia) (Figure 1).4-7

Another public health concern which has a negative impact on a child’s development is micronutrient deficiencies. To determine the micronutrient status of the children, blood analysis was done among subsamples in the study. Blood samples were taken from all children to determine prevalence of anemia. For monitoring Vitamin A and D deficiencies, only blood samples from children aged 6-12 years (11.9 years for Vietnam) were included. Anemia was defined as Hb concentrations <110 g/l for children 0.5-4.9 years; <115 g/l for children aged 5-11.9 years; and <120 g/l for those ≥12 years old. Regardless of age group, Vitamin A deficiency was defined as having serum retinol concentration <0.70 µmol4-7,9; while a concentration <50 nmol/l of circulating 25-hydroxyvitamin D was indicative of Vitamin D insufficiency.4-7,10

As seen in Figure 2, prevalence of anemia was comparable among rural-based and urban-based children in Indonesia, Malaysia and Vietnam.4-5,7 In Thailand, anemia was more prevalent among children in the rural areas.6 But among all the four countries, Malaysia had the lowest number of anemic children.5

In all four countries, Vitamin A deficiency had a low prevalence, with rural-based children being more Vitamin A-deficient compared to their urban counterparts.4-7

Despite being in tropical countries, a high prevalence of Vitamin D insufficiency was observed among the subjects.4-7 Clothing practices, skin pigmentation, limited outdoor activities, high occurrence of overweight/obesity and air pollution are contributing factors to this nutrient insufficiency3-6,8 (Figure 2).

Results of the present study are comparable with previous national surveys regarding nutritional status of children in the four SEA countries.4-7 Health education of parents, caregivers and children must be geared towards proper food preparation, adequate food intake and good hygienic practices. Children must be encouraged to limit television viewing and engage in more outdoor activities.4-7,11 Intensified nutrition strategies (such as oral vitamin D supplementation and iron and vitamin A food fortification) are recognized as a basic pillar for reduction in nutritional deficiencies.

References

  1. WHO (2010). Global nutrition policy review. Geneva.
  2. Best C, Neufingerl N, van Geel L et al. Food Nutrition Bulletin 2010; 31L 400-417.
  3. United Nations Children’s Fund, World Health Organization, The World Bank. UNICEF-WHO-World Bank Joint Child Malnutrition Estimates. 2012.
  4. Sandjaja S, Budiman B, Harahap H et al. British Journal of Nutrition 2013; 110: S11-S20.
  5. Poh BK, Ng BK, Haslinda MDS et al. British Journal of Nutrition 2013; 110: S21-S35.
  6. Rojroongwasinkul N, Kijboonchoo K, Wimonpeerapattana W et al. British Journal of Nutrition 2013; 110: S36-S44.
  7. Nguyen BKL, Thi HL, Do VAN et al. British Journal of Nutrition 2013; 110: S45-S56.
  8. WHO Child Growth Standards (2006) Geneva. http://www.who.int/nutgrowthdb/about/introduction/en/index5.html
  9. Pee de S, Dary O. J Nutr 2002; 132: 2895S-2901S.
  10. Mithal A, Wahl DA, Bonjour JP et al. Osteoporos Int 2009; 20: 1807-1820.
  11. Al-Othman A, Al-Musharaf S, Al-Daghri NM, et al. BMC Pediatrics 2012; 12:92