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Department of Nutritional Physiology, National Institute of Nutrition, Vasco de Quiroga No 15, Tlalpan, Mexico D.F. 14000, Mexico
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONGROWTH STUNTING IN MEXICOCONCLUSIONSREFERENCES |
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KEY WORDS: • growth stunting • micronutrient deficiency • iron • zinc • growth
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONGROWTH STUNTING IN MEXICOCONCLUSIONSREFERENCES |
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, Brooke and Wheeler 1976
, Hansen-Smith et al. 1979
, Lampl et al. 1978
; Malcolm 1970
, Sepúlveda-Amor et al. 1995
); some
supplementation studies that have used milk or soybeans have reported a
height gain with supplementation (Lampl et al. 1978
, Malcolm 1970
). In
those studies, it is not possible to be certain whether this was an
effect of protein per se or whether other nutrients added to the diet
such as phosphorus, calcium, zinc or potassium had a causal role. It is
also clear that the supplementation studies that have used milk or
soybeans have produced increments in height that have been much smaller
than the potential increment expected (Golden 1988
), demonstrating that
other nutrients or other factors might also be involved. In some
populations, it has been demonstrated that delayed growth is not
associated with low protein intakes (Allen 1994
).
Observational studies that showed a widespread existence of marginal
deficiency of some micronutrients and its association with growth
stunting prompted the realization of intervention studies (mainly with
zinc, iron, iodine and vitamin A) (Allen 1994
) to investigate whether
such deficiency was the cause of growth stunting. Supplementation
studies with these micronutrients have also led to conflicting results.
In this paper, we present the results of studies conducted in rural
areas of Mexico to demonstrate the notion that growth stunting occurs
in association with marginal deficiencies of several micronutrients;
consequently, supplementation with single nutrients will produce in
most instances little or no beneficial effect on linear growth.
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GROWTH STUNTING IN MEXICO |
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TOPABSTRACTINTRODUCTIONGROWTH STUNTING IN MEXICOCONCLUSIONSREFERENCES |
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). Growth deficiency was considered as
height for age >2 SD below the median given by NCHS/WHO.
In some of the poorest rural areas, these figures can be as high as
50% of preschool children. Decreased growth rate in children has been
associated with increased morbidity and reduced scholastic achievement
(Martorell et al. 1992a
); it also has long-term negative effects on
physical work capacity and reproduction performance (Martorell et al. 1992a and 1992b
). Effect of zinc and iron supplementation.
Considering the high prevalence of growth stunting in Mexican children
and the potential role of zinc and iron deficiencies in reducing growth
rate, zinc and/or iron supplementation was investigated to determine
whether this would improve significantly the nutritional status and
growth of Mexican preschoolers (Rosado et al. 1997
).
The study was conducted in five rural communities in the central highland plateau of Mexico, located in the State of Mexico, ~150 kilometers northwest of Mexico City. A total of 219 children between 18 and 36 mo of age were randomly assigned to one of four groups according to age, sex and height-for-age deficit. Each of the four groups received a daily supplement consisting of a 20 mL fluid that contained 20 mg of elemental iron as ferrous sulfate, 20 mg of elemental zinc as zinc methionine, 20 mg of elemental zinc plus 20 mg of elemental iron and a placebo, respectively. Supplements were formulated in a flavored beverage, which was given under direct supervision from Monday to Friday for 12 mo. Compliance was excellent; children consumed the supplements 97% of the days and only 25 children dropped from the study before the 12 mo of supplementation were completed.
Anthropometry measurements were collected at baseline before
supplementation and at 6 and 12 mo afterwards. Venous blood was
collected from every preschooler at baseline before supplementation and
at 6 and 12 mo after supplementation for analysis of hemoglobin,
hematocrit, ferritin, zinc, retinol, C-reactive protein,
-tocopherol, vitamin B-12 and riboflavin.
After 12 mo of supplementation, linear growth varied from 8.9 to 9.3 cm/y in the different groups and no difference among them was detected. There was a lack of effect of iron and/or zinc supplementation on growth even though plasma zinc and zinc in red blood cells increased in the zinc-supplemented groups and ferritin increased in the iron-supplemented groups.
Although it is well recognized that zinc deficiency produces delayed
growth and development, the benefits of zinc supplementation on
incremental growth is more controversial. Some studies have found a
positive effect of zinc supplementation on linear growth (Gibson et al.
1992
, Walravens and Hambidge 1976
, Walravens et al. 1983
, Xue-Cun et
al. 1985
), whereas others did not find that effect (Carter et al. 1969
,
Cavan et al. 1993
). In a recent meta-analysis in which 25 zinc
supplementation studies were reviewed, Brown (1995)
found a pooled
effect of 0.2 SD on height and 0.26 SD on
weight. Both effects were positive and small but nevertheless
significant.
The effect of iron nutritional status on growth is even more
controversial. Angeles et al. (1993)
demonstrated a positive effect of
iron and ascorbic acid on linear growth compared with a supplement of
ascorbic acid alone. The effect was attributed to a reduction in
morbidity observed with iron supplementation. Other studies have not
found an effect of iron supplementation on growth (Gershoff et al. 1988
, Migasena et al. 1972
).
The proportion of children with deficient nutritional status of the micronutrients analyzed in the study is shown in Table 1 .At the beginning of the 1-y supplementation, there was a high incidence of anemia and low ferritin, tocopherol, retinol, vitamin B-12, holo TC11 and zinc. Of the total group of children, <7% had no deficiency, 11% had deficiency of one nutrient, 18% had deficiencies of two nutrients and 64% had deficiency of more than two nutrients. The high proportion of some of these deficiencies was present during the 12 mo of observation. The lack of effect on linear growth observed with zinc and iron supplementation could be due to the fact that the children in this study were deficient in several other nutrients, which may in itself have impaired growth or impaired the potential positive effect of zinc and/or iron. Our study suggests that, for interventions directed to reduce retarded growth in populations in which multiple micronutrient deficiencies are suspected, attention to one single nutrient will have little, if any effect.
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) and a
lower incidence of growth stunting (Rivera-Dommarco et al. 1995
).
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The objective of the study was to evaluate the effect of a mixture of
multiple micronutrient supplementation on growth of children living in
a rural Mexican community (Rivera et al., unpublished data). The study
was a randomized, double-blind, community intervention conducted in a
rural community in Xoxocotla in the state of Morelos. A total of 337
children between 8 and 14 mo of age were randomly assigned into two
groups. One group received a supplement (n = 168) and
the other received a placebo (n = 169). Both treatments were
administered 6 d/wk over a period of 12 mo and were ingested under
supervision. The supplement was formulated to contain the nutrients
that are known or expected to be deficient in Mexican children or for
which there is some evidence of low intake (Rosado et al. 1995a and 1995b
). The supplement contained 1 Recommended Dietary Allowance (RDA)
of vitamins D, E, K, niacin, B-1, B-6, folic acid, pantothenic acid,
iodine copper, manganese fluoride and selenium; 1.2 RDA of vitamin A;
and 1.5 RDA of ascorbic acid, riboflavin, vitamin B-12, iron and zinc.
The supplement was formulated into a flavored beverage that contained
30 kcal and no fat or protein. The placebo consisted of a 30-kcal
flavored beverage with no micronutrients added. Both supplements were
developed into a 25-mL flavored beverage. Anthropometry was measured
every month by trained personnel during the observation period;
Z-scores were calculated for weight for age, weight for height and
height for age. At the beginning of the study, information on
characteristics of the house, possession of selected household goods
and parental education was obtained by direct interviewing of the
mothers.
Anthropometry results are shown in Table 3 .Final length was 0.9 cm higher for the group supplemented with multiple micronutrients compared with the placebo group. This difference decreased to 0.6 when adjusting for age, initial length, sex and socioeconomic status. Both values are significant compared with the placebo group (P < 0.05). The difference between the placebo group and the group supplemented with multiple micronutrients is higher when the groups are divided according to socioeconomic status; children of low and medium socioeconomic status of the micronutrient-supplemented group grew ~1 cm more than the same group of children in the placebo group. In this study, we found a positive highly significant effect on linear growth of supplementation with a preparation containing multiple micronutrients. The effect, however, was lower than expected for catch-up growth, suggesting that a full correction of growth stunting requires more than supplementation with the apparently deficient nutrients.
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CONCLUSIONS |
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TOPABSTRACTINTRODUCTIONGROWTH STUNTING IN MEXICOCONCLUSIONSREFERENCES |
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Supplementation with multiple micronutrients produced a significant increment in linear growth. However, even in children supplemented with multiple micronutrients, the actual increment in height was much less than the potential increment expected.
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FOOTNOTES |
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REFERENCES |
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TOPABSTRACTINTRODUCTIONGROWTH STUNTING IN MEXICOCONCLUSIONSREFERENCES |
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21.
Rosado J. L., López P., Muñoz E., Martínez H., Allen L. H.. Zinc supplementation reduces morbidity, but neither zinc nor iron supplementation affects growth of body composition of Mexican preschoolers. Am. J. Clin. Nutr. 1997;65:13-29.
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Walravens P. A., Krebs N. F., Hambidge K. M.. Linear growth of low income preschool children receiving a zinc supplement. Am. J. Clin. Nutr. 1983;38:195-201.
25.
Xue-Cun C., Tain-An Y., Jin-Sheng H., Qiu-Yan M., Zhi-Min H., Li-Xiang L.. Low levels of zinc in hair and blood, pica, anorexia, and poor growth in Chinese preschool children. Am. J. Clin. Nutr. 1985;42:694-700.
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