Intervention in Children With Malnutrition
Condition: Overweight and Obesity; Stunted Growth; Malnutrition, Child; Nutrient Deficiency
MeSH terms: Overweight; Malnutrition; Child Nutrition Disorders; Growth Disorders
Study type: Interventional

Summary: 
      Malnutrition is an epidemiologic problem with high prevalence in Mexico. Mexican children
      present a double burden of malnutrition characterized by the coexistence of undernutrition
      and micronutrient deficiency alongside excess body weight. Malnutrition is caused by
      inadequate nutrition, including micronutrients deficiencies, in which children living in
      rural areas and indigenous populations are disproportionately affected. Malnutrition has been
      associated with an increased risk of metabolic abnormalities like metabolic syndrome (MS),
      diabetes, and cardiovascular disease in adulthood. Nutrition-specific interventions are
      strategies that may reduce or avert malnutrition in children. However, limited intervention
      studies have been implemented in low-income populations, particularly in rural areas.
      Therefore, studies that include nutrition-specific intervention with enriched foods aimed at
      reducing micronutrients deficiencies and that can help in prevention or treatment of
      metabolic conditions in these populations are still needed. Based on the nutritional
      characterization carried out in school children in Chimalhuacán, Mexico State, a formula in a
      powder form was designed for children containing vitamins, minerals, antioxidants, and
      omega-3 fatty acids that can be used to enrich foods. The present study aimed to evaluate the
      effect of a 4-week intervention with cookies enriched with a micronutrient formula on the
      nutritional status in Maya schoolchildren aged 8-10 years. Participants (n=84) were their own
      control, and the investigators measured, at pre- and post-intervention, anthropometric,
      clinical, biochemical, and cognitive parameters; diet and molecular parameters were assessed
      only at pre-intervention. Chi-square test, t-Student paired or Wilcoxon, ANCOVA, and logistic
      regression were performed to analyze the data.
    

Detailed description: 
      Mexican children face both forms of malnutrition: under- and overnutrition. Malnutrition is
      common among children living in rural areas and indigenous populations, where children suffer
      from food insecurity and cannot access quality nutrition with adequate micronutrients levels.
      Studies with vulnerable population groups, such as children, in Mexico have shown that
      micronutrient deficiencies of vitamins A, E, D, C, and minerals like iron, zinc, calcium, and
      selenium exist. Micronutrient deficiencies can affect physiology functions, growth of
      children, cognitive function, and impair metabolic processes at biochemical and cellular
      level. Furthermore, the early exposure of children to malnutrition, in conjunction with the
      existence of genetic susceptibility, may predispose children to develop metabolic
      abnormalities like metabolic syndrome (MetS). Thus, increasing the risk of children
      developing diabetes and cardiovascular diseases in adulthood.

      The investigators decided to implement an intervention study in rural communities in the
      state of Yucatan because this region presents a higher proportion of Maya population than
      other states of Mexico, but also Yucatan has the highest prevalence of both obesity and
      undernutrition in children in the country. Previous studies from the investigators group in a
      Maya child population revealed a frequency of 50% MetS, 34.9% Insulin Resistance (IR), in
      addition to deficiencies of essential micronutrients. Despite the fact micronutrients are
      essential for adequate functioning of metabolic processes, few studies in Mexico propose an
      intervention with enriched food with multiple nutrients such as micronutrients and omega-3
      fatty acids. Also, there is little evidence from micronutrient intervention studies in
      schoolchildren with malnutrition in Mexico, as a strategy to impact on nutritional status and
      preventive metabolic conditions. For instance, a study by García-López S et al in Mexican
      schoolchildren with overweight and MetS showed a decrease in lipid and glycemic profiles when
      supplemented with omega 3-fatty acids for 1 month. Therefore, the present study aimed to
      evaluate the effect of 4-week intervention with enriched cookies containing a micronutrient
      formula designed specifically to target the nutritional deficiencies identified in the
      children. The investigators assessed anthropometric, clinical, biochemical, and cognitive
      parameters; diet and molecular parameters were assessed only at pre-intervention.

        1. Study location: This study was conducted in three elementary schools of Maya rural
           communities of Yucatan. The communities are Xocén, Tahmek, and San José Oriente.

        2. Study design: This study was a paired clinical trial. Participants were their own
           control for the enriched food intervention.

        3. Sample size: The investigators used an equation for finite population. The sample size
           was estimated to have 80% of statistical power and 95% of a confidence level. A 15% was
           considered for calculations for dropout during the intervention. Based on the prevalence
           of malnutrition in Mexico and one community (Xocén), the total number of participants
           was 106.

        4. Sampling procedure: The investigators considered the inclusion and exclusion criterions.
           Participants were assigned with the convenience sampling technique.

        5. Intervention: The intervention consisted of a either a handmade oatmeal cookie or
           industrialized cookies both enriched with a formula FV-UNAM. The handmade oatmeal
           cookies enriched with the supplement formula were administered to schoolchildren from
           Xocén. The industrialized cookies, called Globitos, were donated by DONDÉ cookie factory
           company, and were supplemented with the same formula as the oatmeal cookies. The
           enriched Globitos were distributed to the schoolchildren from Tahmek and San José
           Oriente. The FV formula for children was designed by the Facultad de Química-UNAM. The
           FV formula is in powder form that contains vitamins, minerals, antioxidants, and omega-3
           fatty acids, which are nutrients that have been observed to be deficient in the studied
           schoolchildren populations. The formulation was within the requirements of the Reference
           Daily Intake (RDI) for the Mexican population, according to their age, from the Official
           Mexican Standard (NOM)-051-SCFI/SSA1-2010.

        6. Measurements: A nutritional-clinical face-to-face interview was performed with parents
           or tutors and children. When necessary, assistance from a local translator was used.
           Nutritional data was collected before pre-intervention. Anthropometric, clinical,
           biochemical, and cognitive parameters were collected pre- and post-intervention; diet
           and molecular parameters were assessed only at pre-intervention.

             1. Anthropometric parameters were measured according to the International Society for
                the Advancement of Kinanthropometry (ISAK). Parameters included were: body weight
                (SECA 869), height (SECA 217); wrist, arm, and waist circumference (LUFKIN);
                tricipital skinfold (LANGE); wrist, humerus, and femur diameters (VITRUVIAN). Then,
                the BMI-for-age and height-for-age indicators were estimated and were translated to
                z-score according to the World Health Organization (WHO) classification for growth
                standards. Bone's diameters were translated to z-score and tricipital skinfold to
                percentile.

             2. Body composition (body fat and fat-free-mass) was determined by bioimpedance
                analysis (TANITA BC-1500).

             3. Blood pressure was taken twice with a rest period of 10 minutes. The investigators
                used the average of the two measurements and converted the value to percentile.

             4. Biochemical parameters were collected of peripheral blood samples (8ml) after 12
                hours of fasting in the presence of parents or tutors. The 4ml was used for
                complete blood count and blood chemistry determinations, and also the molecular
                parameters. The rest of the sample (4ml) will be used for the determination of
                micronutrients in serum (vitamin A, vitamin E and vitamin D). Blood samples were
                centrifuged 15 minutes after sample collection and separated into aliquots.
                Aliquots were kept under optimal conditions (2-8◦C) until processing. All
                biochemical parameters were determined by the central laboratory of Hospital Juárez
                de México according to the specific instructions of the manufacturers of the
                commercial kits. The micronutrients will be quantified by high-efficiency liquid
                chromatography (HPLC).

             5. Cognitive test was assessed using a Draw-A-Person Intellectual Ability Test for
                Children, Adolescents and Adults (DAP:IQ), which allows an estimation of
                intellectual ability. The cognitive test was analyzed by two evaluators.

             6. Dietary intake was assessed using a standard 24-hour diet recall questionnaire at
                pre-intervention. This assessment consists of face-to-face interviews with parents
                or tutors, and children. The investigators used household measurements to estimate
                portion sizes of consumed foods and beverages. Dietary intake data was analyzed by
                a dietary analysis program (Nutrimind software). This software uses the Mexican
                Equivalent Food System and U.S. Department of agriculture (USDA) Food database.

             7. Frequency of food intake was estimated using the standard Semi-Quantitative Food
                Frequency Questionnaire (SFFQ), which was specific for the school age Mexican
                population. This assessment was a face-to-face interview with children in presence
                with the teacher. The SFFQ was analyzed using a valid method of Ramírez-Silva I et
                al., 2016.

             8. Molecular parameters included genotypification of genetic polymorphisms that are
                associated with metabolic alteration in Mexican adults and Mexico´s indigenous
                communities. First, the DNA genomic extraction from whole blood was performed using
                Miller technique. Polymorphisms of genes ATP (Adenosine triphosphate) binding
                cassette subfamily A member 1 (ABCA1), Peroxisome proliferator activated receptor
                gamma (PPARG), Glucokinase regulator (GCKR), Cycline-dependent kinase
                inhibitor-2A/B (CDKN2A/2B), Fat mass and obesity-associated (FTO), and Hepatocyte
                nuclear factor 4 alpha (HNF4A) were genotyped using TaqMan® probes in Real-time
                Polymerase Chain Reaction (qPCR) (QS5 from Applied Biosystem). The Hardy-Weinberg
                (H-W) equilibrium was verified. The allelic frequencies were obtained and were
                compared to 1000 Genomes Project reported frequencies.

        7. Adverse effects of the enriched cookies. Any adverse effects were assessed during a
           weekly visit. The information was obtained by teachers, parents or tutors.

        8. Ethics approval. The study protocol was approved by the Ethics Committee of Hospital
           Juárez de México (HJM2315/14-C).

        9. Data Analysis. Data was analyzed using the Statistical Program for Social Sciences
           (SPSS), version 20. Descriptive data was shown with tables pre- and post-intervention.
           Categorical variables were used as percentages. Continuous variables were tested for
           normality and were presented as mean and standard deviation. To determine significance
           of observed differences between pre- and post-intervention measurements the
           investigators used paired t-Student (parametric variables) and Wilcoxon (non-parametric)
           tests. An ANCOVA was performed to identify correlations between nutritional status and
           parameters, and was adjusted by age, gender, and BMI-z-score as fixed variables.
           Logistic regression was used to determine the effects of polymorphism under the risk of
           metabolic abnormality. A 95% confidence level was used, and a P value <0.05 was
           considered statistically significant.
    

Intervention name(s): Experimental intervention group with enriched cookies
Intervention type(s): Dietary Supplement
Intervention description(s): Enriched cookies containing a micronutrients formula (vitamins, minerals, antioxidants, and omega-3 fatty acids) each day (Monday to Friday).
Intervention model: Single Group Assignment
Intervention model description: The intervention consisted of enriched cookies given to children at school for one month. The intervention included two stages. First stage, schoolchildren received placebo cookies (20g of cookies without formula) each day (Monday to Friday) in the morning for 4 weeks. Then, in the second stage, schoolchildren received enriched cookies (20g with a formula FV-UNAM) each day (Monday to Friday) in the morning for 4 weeks. The formula was added to the cookies in a daily dose of 0.33g of organic mix that contained two vitamins, four minerals and omega-3 fatty acids. The exact composition of the formula is a trade secret held by UNAM. Schoolchildren were their own controls because the study was a paired study. In both stages we collected venous blood and anthropometric, blood pressure, and cognitive measurements before the placebo intervention, after 4 weeks from the beginning of formula intervention and post- intervention.
Masking: None (Open Label)
Primary purpose: Prevention
Keywords: Double burden of malnutrition; Enriched food; Micronutrients