Academic Journal of Nutrition 2 (1): 01-09, 2013

ISSN 2309-8902
© IDOSI Publications, 2013
DOI: 10.5829/idosi.ajn.2013.2.1.7466

Effect of Nutritional Status on Growth Pattern

of Stunted Preschool Children in Egypt
1
Wafai Z.A. Mikhail, 1Hassan M. Sobhy, 2Hanaa H. El-sayed,
2
Sahar A. Khairy, 2Hend Y.H. Abu Salem and 2Maysa A. Samy

1
Institute of African Research and Studies, Cairo University, Cairo, Egypt
2
National Nutrition Institute (NNI), Cairo, Egypt

Abstract: Growth retardation is highly prevalent among children in low-income countries. Infections and
inadequate food intake are well-established causes of growth retardation; however, the possible specific role
of micronutrient deficiencies in the etiology of growth retardation and other developmental and health
outcomes has gained attention recently. The aim of the present study was to provide information about
nutritional status of stunted Egyptian preschool children and their dietary intake, which will help in designing
a proper nutrition education massages &appropriate preventive strategies to improve linear growth. The study
was designed as a case control study included (100) Egyptian children aged 2-<6 years old, with delayed linear
growth, proportionate stunted, randomly selected from the stunted outpatient clinic of National Nutrition
Institute (NNI) and results were compared to (50) age, sex and socioeconomic matching control. All participants
were subjected to the baseline assessment (Full history- clinical examination- anthropometric measurements
including weight & height- lab investigation including hemoglobin concentration, serum Ca, Zn, Vit. A, TSH,
T4,T3 & albumin and stool analysis - dietary intake including“ Twenty four-hour recall“ method & food
frequency questionnaire. Results showed that mean height for age Z score is significantly lower among the
stunted compared to the control group. Dietary intake analysis showed that mean intake of all minerals is
significantly lower among stunted children as compared to control group.% intake of RDA from Ca was 57.2%
for stunted as compared to 101.7% for control. Nearly the same pattern was noticed for Mg.while intake of all
macronutrients was significantly lower among stunted compared to the control group. Vitamin A intake of
stunted group represented only 67.5% of RDA as compared to 214.0% of control group; the difference was
highly significant between the two groups. All blood values of Albumin,TSH,T3,T4,Ca, Zn& Vit.A were
significantly lower among stunted group as compared to control, although within normal range, according to
cut off point of each parameter, while both groups were anaemic with no significant differences between the
two groups. As a conclusion, It seemed that dietary intake deficiency of several micronutrients of stunted
children (primarily Ca, Zn, Mg and vitamin A) & all macronutrients intake may play an important role in their
linear growth retardation. Calcium intake level among stunted children was far below the recommended figures.
Nutrition education messages encouraging high consumption of dairy products are needed to counteract this
pattern of low calcium intake. Preventive strategies to prevent stunting and promote healthy eating & milk
consumption are recommended.

Key words: Stunted growth Body mass index (BMI) Nutritional status

INTRODUCTION inadequate nutrition and infection are among factors

thought to play major role in reducing the child’s height-
Stunting is a major health problem worldwide for-age [2]. As a manifestation of chronic under nutrition,
affecting approximately 178 million children under the age stunting has been linked to multiple adverse health
of five [1]. While the etiology of stunting is complex, outcomes that extend beyond childhood into adult life [3].

Corresponding Author: Hend Y.H. Abu Salem, National Nutrition Institute(NNI),

16 Kaser El Einy Street, Cairo, Egypt.
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 Acad. J. Nutr., 2 (1): 01-09, 2013

nadequate intake of dietary energy and protein and against the wall of the stunting clinic and was measured
frequent infections are well-known causes of growth to the nearest 0.1 cm. Z score was calculated for height for
retardation [4-6]. However, the role of specific age using the computer program ANTHRO [version 1.01
micronutrient deficiencies in the etiology of growth 1990].
retardation has gained attention more recently [7-9].
Micronutrient deficiencies are highly prevalent in Laboratory Investigations: Blood samples Collected from
low-income countries and the most probable causes fasting children between (9 and 10 a. m). Serum was
are low content in the diet and poor bioavailability. rapidly separated by centrifugation (3000 rpm 10 min).
More than half of preschool children are anemic and Separated serum aliquots were removed and stored frozen
an estimated 75 million and 140 million preschool at -70°C until analysis was done which included:
children have clinical and subclinical vitamin A
deficiencies, respectively [10]. Less information is *Serum Zn, Cut off point 60-110 µg/dl [14].
available on the prevalence of zinc deficiency, although *Serum Calcium: By Colorimetric determination using the
it has been estimated recently that about half of the kits from BioMerieux France. Cut off point 10-12 mg/dl
world's population is at risk of inadequate intake of [15].
absorbable zinc [11]. * Serum TSH,T3,and T4: By using BIOSOURCE h-OST
Therefore, the aim of the present study was to ELIZA kit manufactured by BioSource Europe S.A. Rue de
provide information about the nutritional status of I'Industrie, 8 B-1400 Nivelles Belgium. Cut off point of
stunted Egyptian preschool children and their dietary TSH= 0.4-7µlu/ml [16], Cut off point of T 3= 1.2-4.2 pg/ml
intake, which will help in designing a proper nutrition [17] Cut off point of T4= 7-22 pg/ml [18].
education massages and appropriate preventive strategies *Serum vit. A: Cut off point < 36-120 µg/dl [19].
to improve linear growth. *Serum Albumin levels; Cut off point 3.8-5.1g/dl [20].
*Hb concentration: Cut off point 11-14gm/dl [21].
MARTERIALS AND METHODS Stool analysis.

Case control study that included (100) stunted Food Intake: Using 24-hour dietary recall and food
preschool children aged (2--<5years) attending the frequency methods.
stunting outpatient clinic of National Nutrition
Institute (NNI), Cairo during the period 6/2011 to 9/2011. 24-Hour Dietary Recall: Data were recorded as grams
All children were clinically free with no complaint consumed, the conversion of household measures to
apart from short stature. Fifty (50) matching children grams was achieved through use of prepared list of
(with normal height for age) were included as a control weight of commonly used household measures in Egypt
group. After taking verbal consent from the parents, each developed by National Nutrition Institute. The energy and
of the studied cases as well as the controls was subjected main nutrients content of the 24 hour food intake was
to the following procedures: computed through the food composition tables of the
NNI, 1993 [22]. The vitamin and mineral contents of food
Clinical History: It included socioeconomic status which and beverages consumed were compared to the
was done according to El-Sherbeny and Fahmy [12], past recommended nutrient intake based on the report of joint
history of breast feeding, family history of similar FAO/WHO Expert Consultation on human vitamin and
condition among siblings, previous diseases or mineral requirements, 2002 [23]. RDA of iron was based on
operations, fractures, history of drug intake including its bioavailability according to the daily diet content of
inhaled or topical preparation; Parental heights and family hem iron source in gm : Low bioavailability < 30 gm of
history were reported; hem iron source, Intermediate 30-90 gm of hem iron source
and High bioavailability > 90 gm of hem iron source.
Thorough Clinical Examination: For clinical evaluation of
nutritional status was conducted by the medical doctor of Food Frequency Method: This method was used to obtain
the clinic; Anthropometric measurements were assessed qualitative descriptive information about usual food and
according to the standard procedure [13]. Weight was consumption pattern for the children grope of food,
measured using Platform Bath Scale. Height was measured including items about : Energy foods as : Cereals and its
using a Raven millimeter which is permanently fixed products, fats, tubers and sweets.

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 Acad. J. Nutr., 2 (1): 01-09, 2013

Tissue building foods as: Meat, chicken, fish, eggs, The results also indicated that 92.7% of stunted boys
legumes, milk and its produces. Protective foods as: & 92% of stunted girls showed delayed bone age
Vegetables and fruits. determined by X ray.
Table (2) showed that the mean height of the stunted
Data Analysis: Data were analyzed in the data boys & girls was (91±8.2 &90.05±7.3 cm) compared to
management and statistical unit of NNI using SPSS (98.7±7.13 &101.68±9.4 cm) for the control group with
(version 5.0.1 Inc Chicago). Data for all variables were highly significant difference between the two groups
presented as means with their standard deviations; (p=0.000). To assess the nutritional status of children,
Comparison of means was made using unpaired student's Height/Age (Z score was used) WHO 2006 [24].
t-test. P values of (<0.05) were considered significant. Mean height for age Z score among the studied
stunted males and females children was (-1.76±1.77
RESULTS and-1.71± 1.81). While mean height for age among the
studied control children was (-0.67±0.98 and -0.2±o.96)
The total number of enrolled children was (150), 100 respectively.
(51% males & 49% females) stunted cases compared to The mean intake of all minerals was significantly
50 (58% males & 42% females) children as controls. lower among stunted children as compared to control
Mean ages of the stunted and the control groups were group.% intake of RDA from Ca was 57.2% for stunted as
(50.37±15.24 & 47.8±1.79) respectively. compared to 101.7% for control. Nearly the same pattern
Table (1) showed the socioeconomic characteristic was noticed for Mg. Otherwise % intake of RDA from
among the studied children. Low social status was other minerals exceeded 100% among both groups except
representing only 17 and 6% of stunted and control for Zn & Selenium which were 94.15 & 94.3% respectively
children respectively. As regard history of breast feeding, among the stunted group only (Table 3).
only 4 and 2% of stunted and control children As regard vitamins intake, Table (4) showed that all
respectively were not breast fed at all with significant mean values of vitamins intake were significantly lower
difference between the two groups (p= 0.015). among stunted group as compared to control. Most of %

Table 1: Percentage distribution of socio economic characteristics among the studied children
Case N=100 Control N=50
-------------------------------------------------------------------- ---------------------------------------------------------------------
Mother Father Mother Father
Socio economic -------------------------- -------------------------- ------------------------ ----------------------------
characteristics No. (%) No. (%) No. (%) No. (%)
Education :-
Illiterate 6 (6%) 7 7% 2 4% 0 0%
literate 13 13% 8 8% 3 6% 4 8%
Preparatory 18 18% 14 14% 5 10% 1 2%
Secondary 36 36% 44 44% 19 38% 24 48%
Vocational education 7 7% 7 7% 3 6% 4 8%
University 19 19% 20 20% 18 36% 17 34%
Post graduate 1 1% 0 0% 0 0% 0 0%
Occupation:-
No Occupation 87 87% 1 1% 40 80% 0 0%
Unskilled worker 0 0% 37 37% 1 2% 12 24%
Skilled worker 0 0% 12 12% 0 0% 6 12%
Semi profession 12 12% 36 36% 8 16% 23 46%
Profession 1 1% 14 14% 1 2% 9 18%
Money spent for food:-
< 50% 42 42% 7 14%
50 % <75% 56 56% 40 80%
>75% 2 2% 3 6%
*Social Status:-
Low 17 17% 3 6%
Middle 67 67% 35 70%
High 16 16% 12 24%

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Table 2: Mean anthropometric measures of the studied children by sex

Case Control
--------------- ----------------
Sex Anthropometric measurements Mean ± S.D Mean ± S.D P
Boys Height 91.9±8.2 98.7±7.13 0 .000***
Height/ age z-score -1.76±1.77 -0.67±0.98 0 .000***
Weight/ height z-score -0.05±1.25 -0.77±1.16 0 .005**
Girls Height 90.05±7.3 101.68±9.4 0 .000***
Height/ age z-score -1.71±1.81 -0.2±0.96 0 .000***
Weight/ height z-score -0.19±1.18 -0.99±2.79 0 .005**
*p = < 0.05 **p = <0.01 ***p= <0.001 NS = Not Significant

Table 3: Mean and % intake of minerals in relation to RDA of the studied children
Case Control
---------------- ---------------
Variables mean± SD mean± SD P
Mean Calcium (mg) intake 314.6±145.3 559.10±256 0.000***
RDA for Ca.(mg/d) 500-600
%intake from RDA 57.2 101.7
Mean Total Iron (mg) intake 9.08±3.6 7.87±3.28 0.04*
RDA for Iron (mg/d) 6
%intake from RDA 131.2 121.3
Mean Total Zinc (mg) intake 4.71±1.74 5.94±2.62 0.001**
RDA for zinc(mg/d) 4.1-5.1
%intake from RDA 94.15 118.72
Mean Copper (mcg) intake 535.7±227.7 611.5±276.3 0.08(NS)
RDA for Cu. (mcg/d) 340-440
%intake from RDA 137.4 156.8
Mean Selenium (mcg) intake 23.57±7.9 30.5±13.2 0.000***
RDA for Se.(mcg/d) 20-30
%intake from RDA 94.3 121.9
Mean Iodine (µg) intake 114.82±44.51 168.37±93.75 0.000***
RDA for Iodine (µg/d) 75-110
%intake from RDA 127.58 187.08
Mean Phosphorus (mg) intake 489.3±147.2 659.6±233.8 0.000***
RDA for P. (mg/d) 460-500
%intake from RDA 102 137.4
Mean Magnesium (mg) intake 58.9±20.4 102.3±36.7 0.000***

RDA for Mg. (mg/d) 60-75

%intake from RDI 78.7 153.8
Recommended Dietary allowance (RDA) Deficiency Surplus

Table 4: Mean and percentage of some vitamins intake in relation to RDA of the studied children
Case Control
--------------- ---------------
Variables mean± SD mean± SD P
Mean Thiamine (mg) intake 0.61±0.25 0.66(±0.25 0.27(NS)
RDA for Thiamine (mg/day) 0.5-0.6
%intake from RDA 111.7 120.4
Mean Riboflavin (mg)intake 1.1±0.79 1.5±0.8 0.009**
RDA for Riboflavin(mg/day) 0.5-0.6
%intake from RDA 201.5 267
Mean Niacin (mg)intake 6.8±2.8 9.0±4.1 0.000***
RDA for Niacin (mg/day) 6-8
%intake from RDA 97 129
Mean Vitamin C (mg) intake 59±67.9 91.3±87.5 0.04*
RDA for Vitamin C (mg/day) 30
%intake from RDA 196.8 291.5
Mean Vitamin A (µg) intake 286.8± 129.9 913.48± 718.9 0.000***
RDA for Vitamin A (µg/d) 400-450
%intake from RDA 67.5 214.0
Source : RDA for Ca, Mg, Zn, FeIodine and Vitamins) [23]
RDA for Cu, P, Se, Carbohydrates and fat )[25]

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Table 5: Mean and percentage of macronutrients intake in relation to RDA of the children studied sample
Case Control
------------------- ------------------
Variables mean± SD mean± SD P
Mean Energy (Kcal) intake 927.35±276.5) 1265.4±332.8 0.000***
RDA for Energy (Kcal/d) 1047-1467
% intake from RDA 74.19 101.2
Mean Total protein (g) intake 36.03±10.83 47.01±16.51 0.000***
RDA for protein (g/day) 13- 37
% intake from RDA 96.09 125.37
Mean Total fat (g) intake 25.04±10.43 38.09±18.84 0.000***
RDA for fat (g/day) 30
% intake from RDA 83.48 126.97
Mean Carbohydrates (g) intake 114.0±11.3 144.38±54.75 0.000***
RDA for Carbohydrates (g/d) 130
% intake from RDA 87.7 111.1
Source: RDA for energy( FAO/WHO/ UNU)[26]
RDA for protein (Anderson [27]

Table 6: Mean (±SD) of some Lab parameters among the studied children
Case Control
---------------- ----------------
Age Parameters Cut Of Point mean±SD mean±SD *P
2 <6 Hb 11 14g/dl 9.90±0.82 10.24±0.61 0.101(NS)
Albumin 3.8 5.1g/dl 4.27±.0.43 5±0.32 0.0002 ***
TSH 0.4 7µlu/ml 2.36±0.77 2.79±0.64 0.003**
T3 1.2 4.2pg/ml 3.03±1.01 4.07±1.39 0.0003***
T4 7 22pg/ml 4.17±1.89 5.22±1.14 0.0003***
Ca. 10 12mg/dl 8.49±1.84 9.66±1.26 0.0008**
Zn 60 110µg/dl 94.11±32.77 140.83±58.17 0.0009**
Vit. A 36 120µg/dl 43.71±17.99 63.45±11.94 0.003**

intake of RDA from vitamins among both groups For Lab parameters, all blood values of
exceeded 100% except for vitamin A intake of stunted albumin, TSH, T3, T4, Ca, Zn & Vit. A were
group which represented only 67.5% of RDA as compared significantly lower among stunted group as
to 214.0% of control group; the difference was highly compared to control, although within normal
significant between the two groups. range, according to cut off point of each
Table (5) showed that, there is a significant decrease parameter, while both groups were anaemic with
in mean intake of macronutrients among stunted group as no significant differences between the two groups
compared to control and their % intake of RDA from (Table 6).
energy(Kcal/day), protein(g/day), fat(g/day) & CHO Stool analysis also indicated parasitic infestation &
(g/d)were less than100%(74.1, 96.09,83.48 & 87.7%) presence of indigestive food in nearly half of the children
respectively. from both groups.
Cases
160 140.9
Control
140

120
95.7 99.4
Mean Values

87.9
100
70 65.4
80 61.6
51.5
60 41.5 40.2
40
7.1 7.8
20

0
FATS AND OILS

FRUITS
CEREALS

MILKS
SUGARS

MEATS

Fig. 1: Mean food frequency pattern from different types of food among the studied children

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 Acad. J. Nutr., 2 (1): 01-09, 2013

Cases
120
Control 99.3 99.4
95.7
100

70.9
80

Mean Values
54.6 56.5
60

40
18.2
20 10.4
1.65 1.9

NUTS
VEGETABLES

LEGUMES

BEVERAGES

TUBERS
Fig. 2: Mean food frequency pattern from different types of food among the studied children

DISCUSSION This study highlighted the micronutrients and

macronutrients consumption among stunted children.
Nutritional status is a primary determinant of a child’s Calcium was the lowest minerals intake in relation to %
health and well-being. The 2008 EDHS [28] found that 29 RDA among stunted 57.2% compared to 101.7% for the
percent of Egyptian children age 0-4 years shows control, followed by magnesium (78.7%), zinc (94.15%)
evidence of chronic malnutrition or stunting. A and selenium (94.3%), while cupper, iron, iodine and
comparison of the results with the 2005 EDHS [29] phosphorus intakes were higher than % RDA. Also the
Suggested that children’s nutritional status deteriorate studied stunting group had low intake of vitamins A &
during the period between the two surveys. For example, Niacin compared to % RDA (67.5 & 97% respectively),
the stunting level increased by 26 percent between the while the intake of Thiamine, Riboflavin and vitamin C
surveys. were higher than % RDA. These results are in agreement
The height-for-age index provides an indicator of with many studies from different countries [32].
linear growth. Children whose height-for-age measures are Along with established risk factors such as frequent
below minus two standard deviations (-2 SD) from the infection and poor weaning foods, there is a strong
median of the reference population are considered short evidence that several micronutrients (primarily zinc, iron
for their age, or stunted [30]. and vitamin A) played important roles in linear growth and
The weight-for-height index measures body mass in deficiencies in these key nutrients may result in stunting
relation to body length. Children whose weight-for-height [33]. Zinc directly influences the growth hormone and
measures are below minus two standard deviations insulin-like growth factor-I systems [34], affects bone
(-2 SD) from the median of the reference population are metabolism [35] and is involved in DNA synthesis
too thin for their height, or wasted [30]. The present study [36, 37]. Zinc and vitamin A affect immune function
showed that height-for-age and the weight/height for [38-40] and thus risk of morbidity and associated growth
stunted children are significantly low compared to the faltering. And, zinc and iron deficiencies can result in
control group. anorexia, leading to decreased intakes of all nutrients,
The previous data of nutritional assessments which can also limit growth [41, 42].
(of the control group) clearly reflected the situation of The results showed that the mean hemoglobin level
nutrition transition in which both under-nutrition and is low among the stunted group (9.90±0.82), although the
over-nutrition problems are prevalent in the same mean albumin, TSH, T3, T4, zinc and vitamin A are within
community. In fact dietary intake data among those normal levels among stunted children, they were
children was a unique situation in which multiple significantly less than the control group. The mean low
deficiencies (like anemia) existed together with excessive serum level of calcium was more apparent among the
energy, protein, fat & CHO intake and this may reflect the stunted children with significant difference (8.49±1.84 &
very poor quality of their diet. 9.66±1.26mg/dl respectively).It is firmly established that
A growing number of studies in the third world high calcium intakes promote bone health; the calcium in
population indicate an emergence of obesity and or the skeleton acts as a reserve supply of calcium to meet
degenerative diseases as a long-term outcome of the body's metabolic needs in states of calcium
malnutrition that resulted in stunted growth [31]. deficiency, calcium deficiency in turn can be easily

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