Prevalence thresholds for wasting, overweight and stunting in children under 5 years.

OBJECTIVE: Prevalence ranges to classify levels of wasting and stunting have been used since the 1990s for global monitoring of malnutrition. Recent developments prompted a re-examination of existing ranges and development of new ones for childhood overweight. The present paper reports from the WHO-UNICEF Technical Expert Advisory Group on Nutrition Monitoring. DESIGN: Thresholds were developed in relation to sd of the normative WHO Child Growth Standards. The international definition of 'normal' (2 sd below/above the WHO standards median) defines the first threshold, which includes 2·3 % of the area under the normalized distribution. Multipliers of this 'very low' level (rounded to 2·5 %) set the basis to establish subsequent thresholds. Country groupings using the thresholds were produced using the most recent set of national surveys. SETTING: One hundred and thirty-four countries. SUBJECTS: Children under 5 years. RESULTS: For wasting and overweight, thresholds are: 'very low' (≈6 times 2·5 %). For stunting, thresholds are: 'very low' (≈12 times 2·5 %). CONCLUSIONS: The proposed thresholds minimize changes and keep coherence across anthropometric indicators. They can be used for descriptive purposes to map countries according to severity levels; by donors and global actors to identify priority countries for action; and by governments to trigger action and target programmes aimed at achieving 'low' or 'very low' levels. Harmonized terminology will help avoid confusion and promote appropriate interventions.

Assessment of the WHO Stunting Framework using Ethiopia as a case study.

Poor linear growth in children <5 years old, or stunting, is a serious public health problem particularly in Sub-Saharan Africa. In 2013, the World Health Organization (WHO) released a conceptual framework on the Context, Causes and Consequences of Childhood Stunting (the 'WHO framework') that identifies specific and general factors associated with stunting. The framework is based upon a global review of data, and we have applied it to a country-level analysis where health and nutrition policies are made and public health and nutrition data are collected. We reviewed the literature related to sub-optimal linear growth, stunting and birth outcomes in Ethiopia as a case study. We found consistent associations between poor linear growth and indicators of birth size, recent illness (e.g. diarrhoea and fever), maternal height and education. Other factors listed as causes in the framework such as inflammation, exposure to mycotoxins and inadequate feeding during and after illness have not been examined in Ethiopia, and the existing literature suggests that these are clear data gaps. Some factors associated with poor linear growth in Ethiopia are missing in the framework, such as household characteristics (e.g. exposure to indoor smoke). Examination of the factors included in the WHO framework in a country setting helps identifying data gaps helping to target further data collection and research efforts. © 2016 John Wiley & Sons Ltd.

Indicators linking health and sustainability in the post-2015 development agenda.

The UN-led discussion about the post-2015 sustainable development agenda provides an opportunity to develop indicators and targets that show the importance of health as a precondition for and an outcome of policies to promote sustainable development. Health as a precondition for development has received considerable attention in terms of achievement of health-related Millennium Development Goals (MDGs), addressing growing challenges of non-communicable diseases, and ensuring universal health coverage. Much less attention has been devoted to health as an outcome of sustainable development and to indicators that show both changes in exposure to health-related risks and progress towards environmental sustainability. We present a rationale and methods for the selection of health-related indicators to measure progress of post-2015 development goals in non-health sectors. The proposed indicators show the ancillary benefits to health and health equity (co-benefits) of sustainable development policies, particularly those to reduce greenhouse gas emissions and increase resilience to environmental change. We use illustrative examples from four thematic areas: cities, food and agriculture, energy, and water and sanitation. Embedding of a range of health-related indicators in the post-2015 goals can help to raise awareness of the probable health gains from sustainable development policies, thus making them more attractive to decision makers and more likely to be implemented than before.

Nutritional disorders in the proposed 11th revision of the International Classification of Diseases: feedback from a survey of stakeholders.

OBJECTIVE: To receive stakeholders' feedback on the new structure of the Nutritional Disorders section of the International Classification of Diseases, 11th Revision (ICD-11). DESIGN: A twenty-five-item survey questionnaire on the ICD-11 Nutritional Disorders section was developed and sent out via email. The international online survey investigated participants' current use of the ICD and their opinion of the new structure being proposed for ICD-11. The LimeSurvey® software was used to conduct the survey. Summary statistical analyses were performed using the survey tool. SETTING: Worldwide. SUBJECTS: Individuals subscribed to the mailing list of the WHO Department of Nutrition for Health and Development. RESULTS: Seventy-two participants currently using the ICD, mainly nutritionists, public health professionals and medical doctors, completed the questionnaire (response rate 16 %). Most participants (n 69) reported the proposed new structure will be a useful improvement over ICD-10 and 78 % (n 56) considered that all nutritional disorders encountered in their work were represented. Overall, participants expressed satisfaction with the comprehensiveness, clarity and life cycle approach. Areas identified for improvement before ICD-11 is finalized included adding some missing disorders, more clarity on the transition to new terminology, links to other classifications and actions to address the disorders. CONCLUSIONS: The Nutritional Disorders section being proposed for ICD-11 offers significant improvements compared with ICD-10. The new taxonomy and inclusion of currently missing entities is expected to enhance the classification and health-care professionals' accurate coding of the full range of nutritional disorders throughout the life cycle.

Childhood stunting: a global perspective.

Childhood stunting is the best overall indicator of children's well-being and an accurate reflection of social inequalities. Stunting is the most prevalent form of child malnutrition with an estimated 161 million children worldwide in 2013 falling below -2 SD from the length-for-age/height-for-age World Health Organization Child Growth Standards median. Many more millions suffer from some degree of growth faltering as the entire length-for-age/height-for-age z-score distribution is shifted to the left indicating that all children, and not only those falling below a specific cutoff, are affected. Despite global consensus on how to define and measure it, stunting often goes unrecognized in communities where short stature is the norm as linear growth is not routinely assessed in primary health care settings and it is difficult to visually recognize it. Growth faltering often begins in utero and continues for at least the first 2 years of post-natal life. Linear growth failure serves as a marker of multiple pathological disorders associated with increased morbidity and mortality, loss of physical growth potential, reduced neurodevelopmental and cognitive function and an elevated risk of chronic disease in adulthood. The severe irreversible physical and neurocognitive damage that accompanies stunted growth poses a major threat to human development. Increased awareness of stunting's magnitude and devastating consequences has resulted in its being identified as a major global health priority and the focus of international attention at the highest levels with global targets set for 2025 and beyond. The challenge is to prevent linear growth failure while keeping child overweight and obesity at bay.

Successive 1-Month Weight Increments in Infancy Can Be Used to Screen for Faltering Linear Growth.

BACKGROUND: Linear growth faltering in the first 2 y contributes greatly to a high stunting burden, and prevention is hampered by the limited capacity in primary health care for timely screening and intervention. OBJECTIVE: This study aimed to determine an approach to predicting long-term stunting from consecutive 1-mo weight increments in the first year of life. METHODS: By using the reference sample of the WHO velocity standards, the analysis explored patterns of consecutive monthly weight increments among healthy infants. Four candidate screening thresholds of successive increments that could predict stunting were considered, and one was selected for further testing. The selected threshold was applied in a cohort of Bangladeshi infants to assess its predictive value for stunting at ages 12 and 24 mo. RESULTS: Between birth and age 12 mo, 72.6% of infants in the WHO sample tracked within 1 SD of their weight and length. The selected screening criterion ("event") was 2 consecutive monthly increments below the 15th percentile. Bangladeshi infants were born relatively small and, on average, tracked downward from approximately age 6 to <24 mo (51% stunted). The population-attributable risk of stunting associated with the event was 14% at 12 mo and 9% at 24 mo. Assuming the screening strategy is effective, the estimated preventable proportion in the group who experienced the event would be 34% at 12 mo and 24% at 24 mo. CONCLUSIONS: This analysis offers an approach for frontline workers to identify children at risk of stunting, allowing for timely initiation of preventive measures. It opens avenues for further investigation into evidence-informed application of the WHO growth velocity standards.

The Global Nutrition Report 2014: actions and accountability to accelerate the world's progress on nutrition.

In 2013, the Nutrition for Growth Summit called for a Global Nutrition Report (GNR) to strengthen accountability in nutrition so that progress in reducing malnutrition could be accelerated. This article summarizes the results of the first GNR. By focusing on undernutrition and overweight, the GNR puts malnutrition in a new light. Nearly every country in the world is affected by malnutrition, and multiple malnutrition burdens are the "new normal." Unfortunately, the world is off track to meet the 2025 World Health Assembly (WHA) targets for nutrition. Many countries are, however, making good progress on WHA indicators, providing inspiration and guidance for others. Beyond the WHA goals, nutrition needs to be more strongly represented in the Sustainable Development Goal (SDG) framework. At present, it is only explicitly mentioned in 1 of 169 SDG targets despite the many contributions improved nutritional status will make to their attainment. To achieve improvements in nutrition status, it is vital to scale up nutrition programs. We identify bottlenecks in the scale-up of nutrition-specific and nutrition-sensitive approaches and highlight actions to accelerate coverage and reach. Holding stakeholders to account for delivery on nutrition actions requires a well-functioning accountability infrastructure, which is lacking in nutrition. New accountability mechanisms need piloting and evaluation, financial resource flows to nutrition need to be made explicit, nutrition spending targets should be established, and some key data gaps need to be filled. For example, many UN member states cannot report on their WHA progress and those that can often rely on data >5 y old. The world can accelerate malnutrition reduction substantially, but this will require stronger accountability mechanisms to hold all stakeholders to account.

Maternal and child undernutrition and overweight in low-income and middle-income countries.

Maternal and child malnutrition in low-income and middle-income countries encompasses both undernutrition and a growing problem with overweight and obesity. Low body-mass index, indicative of maternal undernutrition, has declined somewhat in the past two decades but continues to be prevalent in Asia and Africa. Prevalence of maternal overweight has had a steady increase since 1980 and exceeds that of underweight in all regions. Prevalence of stunting of linear growth of children younger than 5 years has decreased during the past two decades, but is higher in south Asia and sub-Saharan Africa than elsewhere and globally affected at least 165 million children in 2011; wasting affected at least 52 million children. Deficiencies of vitamin A and zinc result in deaths; deficiencies of iodine and iron, together with stunting, can contribute to children not reaching their developmental potential. Maternal undernutrition contributes to fetal growth restriction, which increases the risk of neonatal deaths and, for survivors, of stunting by 2 years of age. Suboptimum breastfeeding results in an increased risk for mortality in the first 2 years of life. We estimate that undernutrition in the aggregate--including fetal growth restriction, stunting, wasting, and deficiencies of vitamin A and zinc along with suboptimum breastfeeding--is a cause of 3·1 million child deaths annually or 45% of all child deaths in 2011. Maternal overweight and obesity result in increased maternal morbidity and infant mortality. Childhood overweight is becoming an increasingly important contributor to adult obesity, diabetes, and non-communicable diseases. The high present and future disease burden caused by malnutrition in women of reproductive age, pregnancy, and children in the first 2 years of life should lead to interventions focused on these groups.

Complementary feeding and attained linear growth among 6-23-month-old children.

OBJECTIVE: To examine the association between complementary feeding indicators and attained linear growth at 6-23 months. DESIGN: Secondary analysis of Phase V Demographic and Health Surveys data (2003-2008). Country-specific ANOVA models were used to estimate effects of three complementary feeding indicators (minimum meal frequency, minimum dietary diversity and minimum adequate diet) on length-for-age, adjusted for covariates and interactions of interest. SETTING: Twenty-one countries (four Asian, twelve African, four from the Americas and one European). SUBJECTS: Sample sizes ranging from 608 to 13 676. RESULTS: Less than half the countries met minimum meal frequency and minimum dietary diversity, and only Peru had a majority of the sample receiving a minimum adequate diet. Minimum dietary diversity was the indicator most consistently associated with attained length, having significant positive effect estimates (ranging from 0·16 to 1·40 for length-for-age Z-score) in twelve out of twenty-one countries. Length-for-age declined with age in all countries, and the greatest declines in its Z-score were seen in countries (Niger, -1·9; Mali, -1·6; Democratic Republic of Congo, -1·4; Ethiopia, -1·3) where dietary diversity was persistently low or increased very little with age. CONCLUSIONS: There is growing recognition that poor complementary feeding contributes to the characteristic negative growth trends observed in developing countries and therefore needs focused attention and its own tailored interventions. Dietary diversity has the potential to improve linear growth. Using four food groups to define minimum dietary diversity appears to capture enough information in a simplified, standard format for multi-country comparisons of the quality of complementary diets.

Association between WHO cut-offs for childhood overweight and obesity and cardiometabolic risk.

OBJECTIVE: To examine the association between cardiovascular risk and childhood overweight and obesity using the BMI cut-offs recommended by the WHO. DESIGN: Children were classified as normal weight, overweight and obese according to the WHO BMI-for-age reference. Blood pressure, lipids, glucose, insulin, homeostasis model assessment-insulin resistance (HOMA-IR) and uric acid levels were compared across BMI groups. ANOVA and tests of linearity were used to assess overall mean differences across groups. Crude and adjusted odds ratios were calculated for adverse plasma levels of biochemical variables. SETTING: Paediatric care centres. SUBJECTS: Children (n 149) aged 8-18 years. RESULTS: About 37 %, 22 % and 41 % of children were classified respectively as normal weight, overweight and obese. There were significant linear mean differences between BMI groups in systolic blood pressure, HDL-cholesterol, TAG, insulin, HOMA-IR and uric acid. Obese children were 10·6 times more likely than normal-weight children to have hypertension; OR for other associations were 60·2 (high insulin), 39·5 (HOMA-IR), 27·9 (TAG), 16·0 (HDL-cholesterol), 4·3 (LDL-cholesterol) and 3·6 (uric acid). Overweight children were more likely than normal-weight children to have hypertension (OR = 3·5), high insulin (OR = 28·2), high HOMA-IR (OR = 23·3) and high TAG (OR = 16·1). Nearly 92 % and 57 % of the obese and overweight children, respectively, had one or more risk factor. CONCLUSIONS: Obesity and overweight defined using the WHO BMI-for-age cut-offs identified children with higher metabolic and vascular risk. These results emphasize the importance of prevention of overweight and obesity in childhood to reduce cardiovascular risk.

Parental height and child growth from birth to 2 years in the WHO Multicentre Growth Reference Study.

Linear growth from birth to 2 years of children enrolled in the World Health Organization Multicentre Growth Reference Study was similar despite substantial parental height differences among the six study sites. Within-site variability in child length attributable to parental height was estimated by repeated measures analysis of variance using generalized linear models. This approach was also used to examine relationships among selected traits (e.g. breastfeeding duration and child morbidity) and linear growth between 6 and 24 months of age. Differences in intergenerational adult heights were evaluated within sites by comparing mid-parental heights (average of the mother's and father's heights) to the children's predicted adult height. Mid-parental height consistently accounted for greater proportions of observed variability in attained child length than did either paternal or maternal height alone. The proportion of variability explained by mid-parental height ranged from 11% in Ghana to 21% in India. The average proportion of between-child variability accounted for by mid-parental height was 16% and the analogous within-child estimate was 6%. In the Norwegian and US samples, no significant differences were observed between mid-parental and children's predicted adult heights. For the other sites, predicted adult heights exceeded mid-parental heights by 6.2-7.8 cm. To the extent that adult height is predicted by height at age 2 years, these results support the expectation that significant community-wide advances in stature are attainable within one generation when care and nutrition approximate international recommendations, notwithstanding adverse conditions likely experienced by the previous generation.

Introducing infant and young child feeding indicators into national nutrition surveillance systems: lessons from Vietnam.

A comprehensive set of infant and young child feeding (IYCF) indicators for international use was published in 2008. We describe the process followed to incorporate these indicators into Vietnam's National Nutrition Surveillance System (NNSS). Following its establishment in 1980, the National Institute of Nutrition introduced the Vietnam NNSS to provide an evidence base for nutrition interventions. While anthropometric indicators based on international standards were regularly used for programme purposes, data on IYCF could not be collected with similar rigor until 2010. In 2009, with support from Alive & Thrive and UNICEF, the NNSS questionnaire was reviewed and additional content incorporated to measure IYCF practices. The tool was pilot-tested in 10 provinces and revised before nationwide roll-out in 2010.The tool comprises four pages, the first three of which focus on collecting data relating to maternal nutrition and IYCF. The last page is flexibly designed to incorporate planners' data requests for other relevant activities (e.g. mass media interventions, food security). Once analysed, the data are presented in a report comprising provincial profiles and maps illustrating IYCF practices. Importantly, the IYCF data have been used for policy advocacy (e.g. maternity leave legislation, advertisement law), programme planning, trend monitoring and capacity building. Adoption of the IYCF indicators was successful due to strategic timing, a phased approach, buy-in from stakeholders and capacity building at all levels to ensure the quality and use of data. Further revisions to the NNSS (e.g. sampling methodology, quality assurance systems) will be important to ensure the reliability of indicators.

The World Health Organization's global target for reducing childhood stunting by 2025: rationale and proposed actions.

In 2012, the World Health Organization adopted a resolution on maternal, infant and young child nutrition that included a global target to reduce by 40% the number of stunted under-five children by 2025. The target was based on analyses of time series data from 148 countries and national success stories in tackling undernutrition. The global target translates to a 3.9% reduction per year and implies decreasing the number of stunted children from 171 million in 2010 to about 100 million in 2025. However, at current rates of progress, there will be 127 million stunted children by 2025, that is, 27 million more than the target or a reduction of only 26%. The translation of the global target into national targets needs to consider nutrition profiles, risk factor trends, demographic changes, experience with developing and implementing nutrition policies, and health system development. This paper presents a methodology to set individual country targets, without precluding the use of others. Any method applied will be influenced by country-specific population growth rates. A key question is what countries should do to meet the target. Nutrition interventions alone are almost certainly insufficient, hence the importance of ongoing efforts to foster nutrition-sensitive development and encourage development of evidence-based, multisectoral plans to address stunting at national scale, combining direct nutrition interventions with strategies concerning health, family planning, water and sanitation, and other factors that affect the risk of stunting. In addition, an accountability framework needs to be developed and surveillance systems strengthened to monitor the achievement of commitments and targets.

Community-based supplementary feeding for promoting the growth of children under five years of age in low and middle income countries.

BACKGROUND: Supplementary feeding is defined as the provision of extra food to children or families beyond the normal ration of their home diets. The impact of food supplementation on child growth merits careful evaluation in view of the reliance of many states and non-governmental organisations on this intervention to improve child health in low and middle income countries (LMIC). This is an update of a Cochrane review first published in 2005. OBJECTIVES: To evaluate the effectiveness of community-based supplementary feeding for promoting the physical growth of children under five years of age in LMIC. SEARCH METHODS: For this updated review  we searched the following databases on 31 January 2011: CENTRAL (The Cochrane Library), MEDLINE (1948 to January week 3, 2011), EMBASE (1980 to week 3, 2011), CINAHL (1937 to 27 January 2011), LILACS (all years), WorldCat for dissertations and theses (all years) and ClinicalTrials.gov (all years). SELECTION CRITERIA: Randomised controlled trials (RCTs) evaluating supplementary feeding in comparison to a control group (no intervention or a placebo such as food with a very low number of nutrients and calories) in children from birth to five years of age in LMIC. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted and analysed the data. MAIN RESULTS: We included eight RCTs (n = 1243 children) that were at relatively high risk of bias. We found high levels of clinical heterogeneity in the participants, interventions and outcome measures across studies. Nevertheless, in order to quantify pooled effects of supplementary feeding, we decided to combine studies according to prespecified characteristics. These were the children's age (younger or older than 24 months), their nutritional status at baseline (stunted or wasted, or not stunted or wasted) and the duration of the intervention (less or more than 12 months). A statistically significant difference of effect was only found for length during the intervention in children aged less than 12 months (two studies; 795 children; mean difference 0.19 cm; 95% confidence interval (CI) 0.07 to 0.31). Based on the summary statistic calculated for each study, the mean difference (MD) between intervention and control groups ranged from 0.48 cm (95% CI 0.07 to 0.89) to 1.3 cm (95% CI 0.03 to 2.57) after 3 and 12 months of intervention, respectively. Data on potential adverse effects were lacking. AUTHORS' CONCLUSIONS: The scarcity of available studies and their heterogeneity makes it difficult to reach any firm conclusions. The review findings suggest supplementary feeding has a negligible impact on child growth; however, the pooled results should be interpreted with great caution because the studies included in the review are clinically diverse. Future studies should address issues of research design, including sample size calculation, to detect meaningful clinical effects and adequate intervention allocation concealment. In the meantime, families and children in need should be provided appropriate feeding, health care and sanitation without waiting for new RCTs to establish a research basis for feeding children. 

Prevalence and trends of stunting among pre-school children, 1990-2020.

OBJECTIVE: To quantify the prevalence and trends of stunting among children using the WHO growth standards. DESIGN: Five hundred and seventy-six nationally representative surveys, including anthropometric data, were analysed. Stunting was defined as the proportion of children below -2sd from the WHO length- or height-for-age standards median. Linear mixed-effects modelling was used to estimate rates and numbers of affected children from 1990 to 2010, and projections to 2020. SETTING: One hundred and forty-eight developed and developing countries. SUBJECTS: Boys and girls from birth to 60 months. RESULTS: In 2010, it is estimated that 171 million children (167 million in developing countries) were stunted. Globally, childhood stunting decreased from 39·7 (95 % CI 38·1, 41·4) % in 1990 to 26·7 (95 % CI 24·8, 28·7) % in 2010. This trend is expected to reach 21·8 (95 % CI 19·8, 23·8) %, or 142 million, in 2020. While in Africa stunting has stagnated since 1990 at about 40 % and little improvement is anticipated, Asia showed a dramatic decrease from 49 % in 1990 to 28 % in 2010, nearly halving the number of stunted children from 190 million to 100 million. It is anticipated that this trend will continue and that in 2020 Asia and Africa will have similar numbers of stunted children (68 million and 64 million, respectively). Rates are much lower (14 % or 7 million in 2010) in Latin America. CONCLUSIONS: Despite an overall decrease in developing countries, stunting remains a major public health problem in many of them. The data summarize progress achieved in the last two decades and help identify regions needing effective interventions.

Worldwide implementation of the WHO Child Growth Standards.

OBJECTIVE: To describe the worldwide implementation of the WHO Child Growth Standards ('WHO standards'). DESIGN: A questionnaire on the adoption of the WHO standards was sent to health authorities. The questions concerned anthropometric indicators adopted, newly introduced indicators, age range, use of sex-specific charts, previously used references, classification system, activities undertaken to roll out the standards and reasons for non-adoption. SETTING: Worldwide. SUBJECTS: Two hundred and nineteen countries and territories. RESULTS: By April 2011, 125 countries had adopted the WHO standards, another twenty-five were considering their adoption and thirty had not adopted them. Preference for local references was the main reason for non-adoption. Weight-for-age was adopted almost universally, followed by length/height-for-age (104 countries) and weight-for-length/height (eighty-eight countries). Several countries (thirty-six) reported newly introducing BMI-for-age. Most countries opted for sex-specific charts and the Z-score classification. Many redesigned their child health records and updated recommendations on infant feeding, immunization and other health messages. About two-thirds reported incorporating the standards into pre-service training. Other activities ranged from incorporating the standards into computerized information systems, to providing supplies of anthropometric equipment and mobilizing resources for the standards' roll-out. CONCLUSIONS: Five years after their release, the WHO standards have been widely scrutinized and implemented. Countries have adopted and harmonized best practices in child growth assessment and established the breast-fed infant as the norm against which to assess compliance with children's right to achieve their full genetic growth potential.

The nutritional status of children in Bhutan: results from the 2008 National Nutrition Survey and trends over time.

BACKGROUND: There are few reports on the nutritional status of Bhutanese children. The objective of this paper is to summarize results from the 2008 National Nutrition Survey and to describe progress achieved during the last two decades. METHODS: A cross-sectional survey of 2376 children aged 6 to 59 months was conducted during November-December 2008 to provide national and regional estimates. A multi-stage cluster sampling method was applied and 40 gewogs/thromdes were selected from each region (Western, Central, Eastern). Guidelines on how to measure length/height and weight followed WHO standardized procedures. Data were analysed for consistency and validation using the software WHO Anthro and the WHO SPSS macro. Underweight, stunting, overweight, wasting and thinness were defined based on the WHO Child Growth Standards. Data from 1986-88 and 1999 national surveys were reanalysed using the WHO standards to describe trends in nutritional status. RESULTS: Nationally, 34.9% Bhutanese preschool children are stunted and 10.4% are underweight. Wasting is 4.7%, with severe wasting close to 2% in rural areas, while overweight affects 4.4% of preschool children. While underweight rates are similar across regions, wasting is substantially more prevalent in the Western region and stunting in the Eastern region. Stunting shows a steep rise during the first two years of life, as high as 40%, and levels off thereafter, while wasting is greatest among children aged 6-24 months and subsequently decreases. The prevalence of stunting fell from 60.9% in 1986-88 to 34.9% in 2008, and underweight declined from 34.0% to 10.4% during same period. The percentage of wasted children dropped from 5.2% in 1986-88 to 2.5% in 1999 but then increased to 4.7% in 2008. CONCLUSIONS: There have been major improvements in the nutritional status of Bhutanese children over the past two decades, however, linear growth retardation remains a significant concern. Early identification of growth faltering is essential for improving the effectiveness of public health programs to prevent stunting. Similarly, wasting rates indicate the need for a system to identify children with severe malnutrition in the isolated communities so that they can receive appropriate care.

Post-partum weight change patterns in the WHO Multicentre Growth Reference Study.

The interplay of factors that affect post-partum loss or retention of weight gained during pregnancy is not fully understood. The objective of this paper is to describe patterns of weight change in the six sites of the World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) and explore variables that explain variation in weight change within and between sites. Mothers of 1743 breastfed children enrolled in the MGRS had weights measured at days 7, 14, 28 and 42 post-partum, monthly from 2 to 12 months and bimonthly thereafter until 24 months post-partum. Height, maternal age, parity and employment status were recorded and breastfeeding was monitored throughout the follow-up. Weight change patterns varied significantly among sites. Ghanaian and Omani mothers lost little or gained weight post-partum. In Brazil, India, Norway and USA, mothers on average lost weight during the first year followed by stabilization in the second year. Lactation intensity and duration explained little of the variation in weight change patterns. In most sites, obese mothers tended to lose less weight than normal-weight mothers. In Brazil and Oman, primiparous mothers lost about 1 kg more than multiparous mothers in the first 6 months. In India and Ghana, multiparous mothers lost about 0.6 kg more than primiparas in the second 6 months. Culturally defined mother-care practices probably play a role in weight change patterns among lactating women. This hypothesis should stimulate investigation into gestational weight gain and post-partum losses in different ethnocultural contexts.

International values for haemoglobin distributions in healthy pregnant women.

BACKGROUND: Anaemia in pregnancy is a global health problem with associated morbidity and mortality. METHODS: A secondary analysis of prospective, population-based study from 2009 to 2016 to generate maternal haemoglobin normative centiles in uncomplicated pregnancies in women receiving optimal antenatal care. Pregnant women were enrolled <14 weeks' gestation in the Fetal Growth Longitudinal Study (FGLS) of the INTERGROWTH-21st Project which involved eight geographically diverse urban areas in Brazil, China, India, Italy, Kenya, Oman, United Kingdom and United States. At each 5 ± 1 weekly visit until delivery, information was collected about the pregnancy, as well as the results of blood tests taken as part of routine antenatal care that complemented the study's requirements, including haemoglobin values. FINDINGS: A total of 3502 (81%) of 4321 women who delivered a live, singleton newborn with no visible congenital anomalies, contributed at least one haemoglobin value. Median haemoglobin concentrations ranged from 114.6 to 121.4 g/L, 94 to 103 g/L at the 3rd centile, and from 135 to 141 g/L at the 97th centile. The lowest values were seen between 31 and 32 weeks' gestation, representing a mean drop of 6.8 g/L compared to 14 weeks' gestation. The percentage variation in maternal haemoglobin within-site was 47% of the total variance compared to 13% between sites. INTERPRETATION: We have generated International, gestational age-specific, smoothed centiles for maternal haemoglobin concentration compatible with better pregnancy outcomes, as well as adequate neonatal and early childhood morbidity, growth and development up to 2 years of age. FUNDING: Bill & Melinda Gates Foundation Grant number 49038.