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AC Doc 14 - Impact of Micronutrient Deficiencies On Growth
AC Doc 14 - Impact of Micronutrient Deficiencies On Growth
DOI: 10.1159/000066397
Abstract
Stunting is a process that can affect the development of a A Healthy Child
child from the early stages of conception and until the
third or fourth year of life, when the nutrition of the moth- Achieving and maintaining optimal child health is a
er and the child are essential determinants of growth. challenge for parents, caregivers, paediatricians, nutrition-
Failure to meet micronutrient requirements, a challeng- ists, public health specialists and for all those who care for
ing environment and the inadequate provision of care, the health and well-being of the future generation. A
are all factors responsible for this condition that affects healthy child is not only a child with no clinically apparent
almost 200 million children under 5 years of age. The illnesses, but a child with adequate physical development,
timing and duration of the nutritional insult leads to dif- both in terms of achieved size and acquired motor skills,
ferent physiological consequences. Growth retardation and with adequate neurological, psychological and emo-
is however just one feature of a complex syndrome tional development. Optimal growth and development
including developmental delay, impaired immune func- therefore encompasses the whole of well-being – physical,
tion, reduced cognitive function and metabolic distur- psychological and social. Furthermore, as we are increas-
bances leading to increased prospective risk of obesity ingly aware of the relationship between current health and
and hypertension. Prevention is possible by undertaking nutritional status and its impact on both immediate and
interventions at all stages of the life cycle, and mainly future risk of disease, we should define a healthy child as
involves the promotion of exclusive breast-feeding until one who is going to be a fit and healthy adult with low
the age of 6 months and the provision of complementary morbidity for chronic diseases, adequate physical work
foods and family foods with adequate micronutrient den- capacity and adequate reproductive performance.
sity. Treatment is possible, at least until the age of 5, and It is presently estimated that malnutrition is responsi-
can lead to reversal of all the symptoms, although fur- ble for 55% of all childhood deaths, but this is probably an
absorption and increased nutrient needs. In contaminated growing child. Appropriate care practices include breast-
environments where sanitary conditions are poor and feeding, complementary feeding, the use of health care
water supplies inadequate, children are very often recur- and good hygiene practices. Education, knowledge, be-
rently infected by parasites or other pathogens that affect liefs, workload and time availability, health and nutrition-
nutrient requirements and utilisation, and have a direct al status of the caregivers, usually the mothers, are essen-
pathological action on skeletal metabolism. A critical tial [28]. In a study carried out in rural Chad, caregiver
period is when complementary foods are introduced and decisions on child feeding, actions taken when a child is
children are exposed to food-borne pathogens [24]. Evi- ill, domestic workload and even caregiver’s level of satis-
dence linking intestinal infections and nutritional status faction with life have shown to have an influence on chil-
(both in terms of anthropometric status and micronu- dren’s height-for-age [29].
trient deficiencies) are extensive. Helminth infections are
known to cause malnutrition through the induction of
anorexia [25], while infections of the gastrointestinal tract Multiple Micronutrient Inadequacy of Diets in
lead to chronic diarrhoea and nutrient malabsorption Developing Countries
[26]. It is thought that Helicobacter pylori infections,
which are easily transmitted from mother to child, are There are several circumstances that might lead to
associated with depressed gastric acid secretion and pre- micronutrient shortages during the lifetime of an individ-
dispose to such repeated infections [27]. ual living in developing countries. Such circumstances
Both nutrient intakes and health are affected by the usually affect a range of micronutrients simultaneously,
provision of adequate care, i.e. time, attention and sup- some of them clustering in the foods commonly con-
port to meet the physical, mental and social needs of the sumed in those countries, i.e. iron, zinc, copper and cal-
Egypt
Maize 169 4.6 – – 1.2 7.5 30.8
Wheat 292 10.8 3.1 0.6 3.9 41.2 3.1
Rice 126 2.5 0.1 0.07 – 2.5 –
Legumes 43 2.9 1.0 – – 27.5 35.0
Dairy 59 2.8 0.4 – 0.3 102.0 28.2
Meat 85 5.2 0.8 – 0.9 2.7 3.6
Fats 162 – – – – – –
Total 936 28.8 5.4 0.7 6.3 183 100.7
Average desired 4.0 0.6 6.0 450 400
Mexico
Maize 551 15 – – 4.0 24.4 100.5
Wheat 75 2.7 0.8 0.1 1.0 10.5 0.8
Rice 26 0.5 0.02 0.01 – 0.5 –
Legumes 80 5.4 0.7 – – 16.4 35
Dairy 66 3.1 0.4 – 0.3 114 30.3
Meat 60 3.7 0.6 – 0.7 1.9 2.5
Fats 98 – – – – – –
Total 956 30.4 2.5 0.1 6.0 185 199.1
Average desired 4.0 0.6 6.0 450 400
Kenya
Maize 369 10.0 – – 2.7 16.3 67.3
Wheat 24 0.9 0.2 0.05 0.3 3.3 0.26
Rice 41 0.8 0.04 0.02 – 0.8 –
Legumes 83 5.6 1.9 – – 53 57.5
Dairy 59 2.8 0.25 – 0.3 102 28.2
Meat 6 0.37 0.06 – – 0.19 0.25
Fats 29 – – – – – –
Total 611 20.4 2.4 0.07 3.3 175.6 163.5
Average desired 4.0 0.6 6.0 450 400
Note: Food intake data are taken from reference 58, nutrient content has been calculated by estimating food
quantities from energy intake and by applying food composition data contained in reference 59, and average require-
ments are taken from reference 60.
his peers and will resemble a younger child, usually 2–3 Berkman et al. [44] showed that stunted growth caused by
years younger. Stunting is also associated with a develop- chronic malnutrition during the first 2 years of life had an
mental delay, with retarded achievement of the main adverse affect on a child’s cognitive ability later in child-
child development milestones, such as walking. This hood. Stunting is also associated with increased child
might create an overall comparative disadvantage in an morbidity and mortality [45]. A very low height-for-age is
already difficult environment. In Filipino children, severe the single strongest predictor of childhood mortality in the
stunting at age 2 was associated with later deficits in cog- first 5 years of life [46].
nitive ability [42] and reduced school performance has A stunted child also has a higher risk of developing
been observed in stunted children in Guatemala [43]. chronic diseases, impaired fat oxidation such as occurs in
obesity, and reduced glucose tolerance. Hoffman et al. indicates that stunting is by no means a condition affect-
[47] tested the hypothesis that nutritional stunting is asso- ing just the skeletal system, although the most apparent
ciated with impaired fat oxidation in poor Brazilian chil- and easily diagnosable feature is small stature. In order to
dren. Stunted children were more likely to have problems advocate for a wider understanding of the problem we
oxidising fat and, as a result, stored more fat in their adi- would like to propose the denomination of ‘stunting syn-
pose tissues. The mechanisms behind this relation are drome’, since a syndrome is a disease entity with multiple
unclear, but the researchers speculated that long-term systemic features that are sometimes maintained through-
undernutrition might have damaged the enzymes and out life. Stunting cannot be considered a form of cost-free
hormones responsible for optimal lipid oxidation. Stunt- adaptation or just an indicator of socio-economic status.
ing can also lead to increased risk of hypertension. In a Small is not ‘beautiful’ and a stunted child is by no means
study performed in Jamaica, Gaskin et al. [48] found that a healthy child, nor is going to be a fit and healthy adult.
stunting in the first 2 years of life was associated with ele- Are the features of the stunting syndrome just a coinci-
vated systolic blood pressure at age 7–8 years. dence or is there a common basis for their origin? We
As previously stated, the stunted child is going to be an have discussed that stunting might result from past expo-
adult of small stature. A small adult has some functional sure to multiple micronutrient deficiencies that may still
limitations compared to a taller one, such as reduced be present. In a few cases the simultaneous presence of
working capacity. In societies where manpower is essen- stunting and micronutrient deficiencies has been demon-
tial for subsistence this may have further consequences on strated. A study among pre-schoolchildren in Brazil docu-
the health and well-being not only of the individual, but mented an association of stunting, diarrhoea and anaemia
also of his/her dependants [49]. Stunted individuals often [51], and another study among schoolchildren in Tanza-
remain in a state of poverty throughout their lives, as they nia showed high rates of both stunting and anaemia [52].
are not able to produce the extra income that might allow In most cases the micronutrient status of stunted children
them to escape the cycle of mere subsistence. Reproduc- has not been investigated, both because of the technical
tive performance may also be affected by stature: a small difficulties and because of the failure to identify stunting
woman will usually deliver a small child. The occurrence as an active condition of poor health. Poor zinc status
of IUGR is higher in stunted girls [50] and this creates an would compromise immunity and neurological function;
inter-generational cycle of stunting (fig. 1). iron and copper deficiency would produce anaemia and
The combined presence of growth retardation, devel- affect development of cognitive function, and inadequate
opmental delay, defects in cognitive function, defects in vitamin A status would also lead to increased susceptibili-
substrate metabolism, increased morbidity and mortality ty to infections (table 3). In other words, the outcome typ-
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