Post on 20-Mar-2017
Factors Associated With Early
Growth in Egyptian
Infants: Implications for
Addressing the Dual Burden
of Malnutrition
Presenter:
Core Group Fall Meeting, October 8, 2015
Justine Kavle, PhD, MPH
Senior Technical Officer, MCSP & PATH
Acknowledgements:
Study Team/Collaborators
Dr. Valerie Flax, University of North Carolina, USA
Dr. Ali Abdelmegeid, Jhpiego/MCSP and Mr. Farouk Salah, MCHIP Smart
Project Egypt
Ms. Seham Hafez, study coordinator, American University in Cairo (AUC)
Dr. Gulsen Saleh, Nutritionist & local PI, MCHIP Smart Project, Egypt
Dr. Mervat Ahmed Fouad, Dr. Doaa Hamed, Dr. Magda Ramzy, Nutritionists
affliated with National Nutrition Institute of Egypt
Ms. Rae Galloway, Maternal and Child Survival Program (MCSP)/PATH
3
One in four Egyptian children are stunted and 15% of children
younger than 5 years is overweight
Egypt faces “ the double burden of malnutrition”
Black, 2013, Lancet
Short term: Decreased mortality, morbidity, health expenditures, improved cognitive
development
Adequate growth and development: attainment of height potential and adequate weight
Household and family factors- maternal diet, care practices, food allocation
Community and Societal factors - Access to food and water, beliefs and norms, caregivers and care practices, agriculture and food
systems
Early initiation and exclusive breastfeeding
Adequate complementary
feeding – quantity, quality, diversity,
frequency
Prevention of infection
Long term: Decreased obesity and illnesses,
increased school performance, learning
capacity, work productivity, GDP
WHO Framework on Prevention of Stunting*
*Kavle et al 2014, Adapted from Stewart, 2013
Dual burden of malnutrition has consequences
for health and economic development
• Stunted children become stunted adults
• Decreased work capacity, productivity,
• Increased risk of obesity and other diseases
• Economic cost
• 20.3 billion Egyptian pounds – 1.9% gross domestic
product – losses in labor productivity due to stunting
• $9.1 billion Egyptian pounds - losses due to chronic
diseases due to obesity
Study Rationale, Objectives, and Methodology
Rationale for study: Stunting in children has nearly doubled in
Lower Egypt, which coincided with the avian influenza
outbreak, yet little is known about what may explain this rise
18 19
29
2124
36 36
2724
31
Frontier Lower Egypt Upper Egypt Urban Gov. All Egypt
Egypt Demographic and Health Surveys
2005 2008
Study Sites: Allow for comparisons between highest and
lowest levels of stunting in Smart Project sites
Kafr Shokr,
Qaliobia, Lower
Egypt
El-Maragha,
Sohag, Upper
Egypt
Four Part Implementation Science Study Examining
Factors Related to Stunting
Lower Egypt
1. Prospective follow-up of children’s
growth in the first year of life
(birth-12 months)
N =295
2. In-depth interviews
with pregnant and
postpartum women
N = 120
3.TIPS Mothers
with children less than 2 years
– Qualitative,
diet
N = 150
4. In-depth interviews with
fathers, grandmothers
and health workers
N= 120
Upper Egypt
Objectives
• To determine if there were differences in growth patterns
and factors related to growth in Lower and Upper Egypt
within the context of a U.S government funded maternal and
child health program
• To examine the relationship between weight and length to
ascertain if weight loss in any two-month interval
contributed to stunting at 12 months of age
Methods
• Longitudinal follow-up - 295 mother-infant pairs
• Data collection by CHW home visits- birth to 1 year
• Weight, length - z-score calculated WHO growth standard
• Program exposure
• Maternal report of infant illness
• 24 hour recall - dietary intake – trained nutritionists
• Multivariate mixed models- patterns/predictors of growth
• Weight-for age, length for age, weight for length
• Controlled for sex, maternal height, parity, maternal education & birth z-score
• Accounted for clustering and measuring same individual – over time
• Logistic regression – weight loss and stunting
Study data collection and MCHIP/SMART
program elements in Egypt
Study visits Data collection elements Elements of MCHIP/SMART
program
Birth Infant weight and length
Socio-demographic information
2 months*
Maternal weight and length
• Counselling session on what
to expect during the first
pregnancy
• Monthly session on good
nutrition during pregnancy
• Message on danger signs
during pregnancy
Exposure to program elements
• Receipt of iron pills
• Message on importance of
iron pills to avoid anemia
• Message on plan for
childbirth
• Message on mother and
infant health after delivery
*SMART program exposure levels: Low 0-5 elements, Medium = 6-10 elements, High = 1-15 elements
Study data collection and MCHIP/SMART
program elements in Egypt
Study visits Data collection elements Elements of
MCHIP/SMART program
4 months*
6, 8, 12 months**
Infant weight and length
• Receipt of medical examination
• Attendance of husband/mother-in-law at any awareness session
• Messages on feeding** when sick, care of child when sick, family planning and handwashing
• Messages on complementary feeding**
Exposure to program
elements
Infant dietary intake
*SMART program exposure levels: Low = 0-3 elements, Medium = 3-5 elements, High = 6-8 elements
**SMART program exposure levels: Low = 0-3 elements, Medium = 4-6 elements, High = 7-9 elements
Key Findings
Characteristics of mothers and infants,
Lower and Upper Egypt
Characteristic Lower Egypt
(n=142) Upper Egypt
(n=135)
Maternal
Mean age at delivery (±SD), years
25.7 ± 4.3 27.8 ± 5.7**
Mean height at 2 months postpartum
(±SD), cm 159.5 ± 6.8 158.5 ± 5.0
Mean parity (±SD) 1.1 ± 1.2 1.7 ± 1.7**
Completed secondary or higher level education, %
(n) 76 (108) 49 (80)***
Infant’s sex % (n)
Female 46 (66) 51 (69)
**p< 0.01, ***p < 0.001
Kavle et al., 2015
Percentage of infants, stunted and wasted,
Lower and Upper Egypt
8 6 5
12
24
10
3
18 16 11 10
4 1 1 0
14
7 5 2 1
0%
10%
20%
30%
40%
50%
60%
70%
80%
Birth 4 months 6 months 8 months 12 months
% Infants Stunted % Infants Stunted % Infants Wasted % Infants Wasted
Percentage of infants, underweight and
overweight, Lower and Upper Egypt
3 3 1 0 0 2 6 5 4 4
13
6 10
19
30
11
2
15 17
10
0%
10%
20%
30%
40%
50%
60%
70%
80%
Birth 4 months 6 months 8 months 12 months
% Infants Underweight % Infants Underweight
% Infants Overweight % Infants Overweight
Predicted patterns of infant growth:
weight-for age z-score, length-for-age z-score in Egyptian
infants
Kavle et al., 2015
-1.5
-1
-0.5
0
0.5
1
1.5
2
0 2 4 6 8 10 12
Pre
dic
ted
we
igh
t-fo
r-ag
e z
-sco
re
Age (months)
-1.5
-1
-0.5
0
0.5
1
1.5
2
0 2 4 6 8 10 12
Pre
dic
ted
len
gth
-fo
r-ag
e z
-sco
re
Age (months)
Compared to 4 month visit, all visits associated with higher WAZ and lower LAZ p< 0.05 ------ Lower Egypt Upper Egypt
Predicted weight-for-length z-score in Egyptian
infants
Kavle et al., 2015
-1.5
-1
-0.5
0
0.5
1
1.5
2
0 2 4 6 8 10 12Pre
dic
ted
we
igh
t-fo
r-le
ngt
h z
-sco
re
Age (months)
Lower Egypt Upper Egypt
Compared to 4 month visit, all visits associated with higher WLZ p< 0.05
Predictors of growth, infants 4 & 6 months of age
4 months 6 months Lower Upper Lower Upper Morbidity Diarrhea (%) 16 17 20 21 Fever (%) 41 42 50 50
Dietary diversity
Mean (SD) number of food groups
0.5 ± 0.8 0.8 ± 0.8 2.0 ± 0.8 1.7 ± 1.0
Minimum dietary diversity (%)
17 21 7 9
Smart Program Exposure
Low (%) 40 33 59 56
Medium (%) 38 39 32 33
High (%) 22 28 9 11
Kavle et al., 2015
Predictors of growth, infants 8 & 12 months of age
8 months 12 months
Lower Upper Lower Upper
Morbidity
Diarrhea (%) 21 10 12 13
Fever (%) 46 54 39 53
Dietary diversity
Mean (SD) number of food groups
2.9 ± 1.0 2.7 ± 1.1 3.6 ± 1.0 3.6 ± 1.1
Minimum dietary diversity (%)
27 32 52 59
Smart Program Exposure
Low (%) 69 76* 66 76**
Medium (%) 12 17 17 24
High (%) 19 8 17 0
*p <0.05, **p< 0.001
Factors associated with infant growth
Upper and Lower Egypt
- Minimum dietary diversity was significantly associated with
weight for length Z-score in Lower Egypt
- 15-20% of energy intake comprised of junk/processed foods,
only half met WHO cut-off for dietary diversity
- No significant association with fever/ diarrhea or program
exposure and growth outcomes
- Weight loss at any interval was associated with greater odds
of stunting ( OR 2.0, p < 0. 05), Lower Egypt only
Kavle et al., 2015
Study Limitations
• Only 295 infants – larger sample size may have aided our
ability to detect associations
• Focus on period of infancy, yet stunting peaks at 18-23 months
• Lack of association of illness with growth
• Difficulty obtaining data on severity of illness by maternal
interview
Kavle et al., 2015
Implications for nutrition programs:
stunting and overweight
• Overweight and stunting begin in the first year of life
• 25% of infants stunted and 30% overweight by 12 months
• Weight loss during first year of life associated with
stunting at 12 months of age in Lower Egypt.
• Infant and young child nutrition programs need to
promote dietary quality while addressing dietary intake
patterns, reliance on energy-dense processed foods
• Need to develop interventions for double burden of
malnutrition
Kavle et al., 2015
Study findings published in Maternal and Child Nutrition
Journal Sept, 16, 2015 - Free open access
http://onlinelibrary.wiley.com/doi/10.1111/mcn.12213/abstract
For more information, please visit
www.mcsprogram.org
This presentation was made possible by the generous support of the American people through the
United States Agency for International Development (USAID), under the terms of the Cooperative
Agreement AID-OAA-A-14-00028. The contents are the responsibility of the authors and do not
necessarily reflect the views of USAID or the United States Government.
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