Mercedes de Onis’s research while affiliated with World Health Organization WHO and other places

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.

Intrauterine growth retardation (IUGR) refers to fetal growth that has been constrained in utero. It results in newborns that have not attained their full growth potential and are already malnourished at birth. Fetuses that suffer from growth retardation have higher perinatal morbidity and mortality and are more likely to experience poor cognitive development and neurologic impairment during childhood. Research shows that as adults IUGR babies have increased risk of cardiovascular disease, high blood pressure, diabetes, and related diseases. Moreover, IUGR contributes to the cycle of malnutrition between generations. The implications of this cycle for both human and socioeconomic development of the affected populations are enormous. SITUATION IN THE DEVELOPING WORLD Human growth is defined as an increase in size over time, not only in the fetus, but throughout childhood until the time of skeletal fusion. Size at the time of birth, therefore, is a function of two factors: the rate of fetal growth and the duration of gestation. But because valid assessment of the duration of pregnancy is difficult to obtain in developing countries, the prevalence of low birth weight has been often used as a proxy to determine the magnitude of IUGR. The availability and quality of birth-weight data is also problematic. Despite these constraints, recent estimates suggest that currently about 11 percent of newborns, or 12.6 million infants, suffer from low birth weight at term (the IUGR proxy). The magnitude of the problem varies widely across countries and geographical regions (see table). Low birth weight at term is especially common in South Central Asia, where 21 percent of newborns are affected, accounting for about 64 percent of all affected newborns worldwide. Low birth weight at term is also common in Middle and Western Africa, but much less so in Latin America and the Caribbean. It is important to note that in the poorest developing countries, a large proportion of newborns, and not just those below an arbitrary cutoff point, are likely to suffer some degree of prenatal growth retardation.

Background: Low birthweight (LBW) of less than 2500 g is an important marker of maternal and fetal health, predicting mortality, stunting, and adult-onset chronic conditions. Global nutrition targets set at the World Health Assembly in 2012 include an ambitious 30% reduction in LBW prevalence between 2012 and 2025. Estimates to track progress towards this target are lacking; with this analysis, we aim to assist in setting a baseline against which to assess progress towards the achievement of the World Health Assembly targets. Methods: We sought to identify all available LBW input data for livebirths for the years 2000-16. We considered population-based national or nationally representative datasets for inclusion if they contained information on birthweight or LBW prevalence for livebirths. A new method for survey adjustment was developed and used. For 57 countries with higher quality time-series data, we smoothed country-reported trends in birthweight data by use of B-spline regression. For all other countries, we estimated LBW prevalence and trends by use of a restricted maximum likelihood approach with country-level random effects. Uncertainty ranges were obtained through bootstrapping. Results were summed at the regional and worldwide level. Findings: We collated 1447 country-years of birthweight data (281 million births) for 148 countries of 195 UN member states (47 countries had no data meeting inclusion criteria). The estimated worldwide LBW prevalence in 2015 was 14·6% (uncertainty range [UR] 12·4-17·1) compared with 17·5% (14·1-21·3) in 2000 (average annual reduction rate [AARR] 1·23%). In 2015, an estimated 20·5 million (UR 17·4-24·0 million) livebirths were LBW, 91% from low-and-middle income countries, mainly southern Asia (48%) and sub-Saharan Africa (24%). Interpretation: Although these estimates suggest some progress in reducing LBW between 2000 and 2015, achieving the 2·74% AARR required between 2012 and 2025 to meet the global nutrition target will require more than doubling progress, involving both improved measurement and programme investments to address the causes of LBW throughout the lifecycle. Funding: Bill & Melinda Gates Foundation, The Children's Investment Fund Foundation, United Nations Children's Fund (UNICEF), and WHO.

Recent evidence suggests that enteropathy of the gut due to environmental conditions (i.e., environmental enteropathy [EE]) in young children is negatively associated with linear growth. Using a case-control study design, we examined the potential determinants of stunting in stunted and non-stunted children 22-28 months of age. Potential determinants included inflammation biomarkers C-reactive protein, alpha-1-acid glycoprotein (AGP), and endotoxin-core antibody (EndoCAb) measured in serum samples; enteropathy markers alpha-1-antitrypsin, neopterin, myeloperoxidase (MPO) measured in stools samples; and demographic, health, feeding, and household characteristics. We also explored the determinants of EE by testing associations of composite EE scores and individual biomarkers with potential risk factors. Fifty-two percent of children (n = 310) were found to be stunted, and mean height-for-age Z scores (HAZ) were -1.22 (SD ± 0.56) among non-stunted (control) children and -2.82 (SD ± 0.61) among stunted (case) children. Child HAZ was significantly (P < 0.05) and inversely associated with AGP, and child stunting was significantly associated (P < 0.05) with low dietary diversity, severe household hunger, and absence of soap in the household. Alpha-1-acid glycoprotein and EndoCAb concentrations were also significantly higher (P < 0.05) among children in households with no soap. Our study documented a seemingly localized cultural practice of young children (25%) being fed their dirty bathwater, which was associated with significantly higher concentrations of MPO (P < 0.05). Alpha-1-acid glycoprotein showed the most consistent associations with child growth and hygiene practices, but fecal EE biomarkers were not associated with child growth. The lack of retrospective data in our study may explain the null findings related to fecal EE biomarkers and child growth.

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’ (<2·5 %), ‘low’ (≈1–2 times 2·5 %), ‘medium’ (≈2–4 times 2·5 %), ‘high’ (≈4–6 times 2·5 %) and ‘very high’ (>≈6 times 2·5 %). For stunting, thresholds are: ‘very low’ (<2·5 %), ‘low’ (≈1–4 times 2·5 %), ‘medium’ (≈4–8 times 2·5 %), ‘high’ (≈8–12 times 2·5 %) and ‘very high’ (>≈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.

The healthy growth and development of infants and young children is of paramount importance for children to develop their full physical and mental potentials. Child growth is internationally recognized as the best global indicator of physical well-being in children and a number of international goals, like the World Health Assembly global targets for 2025, include growth-related targets for stunting, wasting, and overweight among children below 5 years. The consequences of poor child growth in terms of mortality, morbidity, and impaired cognitive development are severe and far-reaching. There are also important consequences in adult life in terms of body size, work and reproductive performances, and risk of chronic diseases. Assessing child growth is not difficult, but requires adherence to key principles and attention to detail. This chapter reviews concepts, indicators, and growth standards for assessing impaired fetal and child growth; describes the magnitude and geographical distribution of growth retardation in developing countries; outlines the main health and social consequences of impaired growth in terms of morbidity, mortality, child development, and adult life consequences; and reviews interventions aimed at promoting healthy growth and development.

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.

Household, child, and women English questionnaires used by the 2013 SLMS. (PDF)

To identify the factors associated with anemia and to document the severity of micronutrient deficiencies, malaria and inflammation, a nationally representative cross-sectional survey was conducted. A three-stage sampling procedure was used to randomly select children <5 years of age and adult women from households in two strata (urban and rural). Household and individual data were collected, and blood samples from children and women were used to measure the prevalence of malaria, inflammation, and deficiencies of iron, vitamin A, folate, and vitamin B12. 839 children and 945 non-pregnant women were included in the survey. In children, the prevalence rates of anemia (76.3%; 95% CI: 71.8, 80.4), malaria (52.6%; 95% CI: 46.0, 59.0), and acute and chronic inflammation (72.6%; 95% CI: 67.5, 77.1) were high. However, the prevalence of vitamin A deficiency (17.4%; 95% CI: 13.9, 21.6) was moderate, and the prevalence of iron deficiency (5.2%; 95% CI: 3.3, 8.1) and iron-deficiency anemia (3.8%; 95% CI: 2.5, 5.8) were low. Malaria and inflammation were associated with anemia, yet they explained only 25% of the population-attributable risk. In women, 44.8% (95% CI: 40.1, 49.5), 35.1% (95% CI: 30.1, 40.4), and 23.6% (95% CI: 20.4, 27.3) were affected by anemia, malaria, or inflammation, respectively. The prevalence rates of iron deficiency (8.3%; 95% CI: 6.2, 11.1), iron-deficiency anemia (6.1%; 95% CI: 4.4, 8.6), vitamin A deficiency (2.1%; 95% CI: 1.1, 3.1) and vitamin B12 deficiency (0.5%; 95% CI: 0.2, 1.4) were low, while folate deficiency was high (79.2%; 95% CI: 74.1, 83.5). Iron deficiency, malaria, and inflammation were significantly associated with anemia, but explained only 25% of cases of anemia. Anemia in children and women is a severe public health problem in Sierra Leone. Since malaria and inflammation only contributed to 25% of anemia, other causes of anemia, such as hemoglobinopathies, should also be explored.