Global Landscape of Nutrient Inadequacies in Toddlers and Young Children
Toddlers and young children need an adequate and diverse diet to provide all of the nutrients required for optimal growth and development. Unfortunately, undernutrition and inadequate intakes of vitamins and minerals are still identified by the World Health Organization (WHO) as major public health threats for young children along with growing overweight and obesity [1]. Organizations like WHO and the World Bank focus on iron, zinc, vitamin A, and iodine for children ≤5 years of age. Prevalence of anemia in children ≤5 years is highest in sub-Saharan Africa (59.9%) and South Asia (55.1%). Anemia, along with vitamin A deficiency and stunting, leads to an "alarmingly high" hidden hunger index in these regions [2].
In addition to the data from these organizations, individual-level food consumption surveys are needed to provide a fuller picture of food and nutrient intakes in different countries. However, these surveys are generally available in higher-income countries and are less common in low- and middle-income countries in regions such as Africa, Eastern
Europe, and Southeast Asia [3]. Even among countries with a food consumption survey, not all collect data on young children. In Europe, only about two-thirds of the countries report energy and nutrient intakes for children ≤5 years [4]. National surveys in the USA (National Health and Nutrition Examination Survey, NHANES) and Australia (National Nutrition and Physical Activity Survey, NNPAS) start only from the age of 2 years. Some national surveys also lack data on the full complement of nutrients required in the diet.
To help fill these gaps, several studies have been done to focus specifically on young children. The South East Asian Nutrition Survey (SEANUTS) conducted studies in Indonesia, Malaysia, Thailand, and Vietnam. The Feeding Infants and Toddlers Study (FITS) is a series of cross-sectional studies in the USA, starting in 2002 with subsequent
surveys collected in 2008 and 2016. FITS provides comprehensive nutrient intake data for more than 5,000 toddlers and young children. It has also been used as a model to analyze national survey data on toddlers and young children from other countries, including China, Mexico, Russia, and the Philippines [5].
Where detailed dietary intake studies are available, we find wide ranges in energy intakes for 2- to 3-year-old children, with lower intakes in the Philippines (839 kcal/day) and Indonesia (965 kcal/day), and higher intakes in Brazil (1,650 kcal/day), the USA (1,379 kcal/day), and Mexico (1,367 kcal/day). Energy intakes were intermediate in Russia (1,243 kcal/day), Germany (1,075 kcal/day), and China (1,189 kcal/ day). Energy intakes corresponded with higher rates of stunting in the Philippines, and higher rates of overweight and obesity in Brazil, North America, and Europe [2]. The distribution of energy from protein, fat, and carbohydrates also differs by country, with higher carbohydrate and lower fat intakes in Southeast Asia (Fig. 1).
Dietary fiber and vitamin D intakes are generally below recommendations for toddlers and young children (Table 1). Other nutrient gaps differ by country and are related to food availability and local dietary habits. Toddlers in the USA, for example, regularly consume dairy products, and fewer than 10% fall below recommendations for calcium intakes. In the Philippines, however, where consumption of dairy foods is rare, 66–84% of 2- to 4-year-old children are below recommendations. For vitamin E, we see relatively low levels of inadequacy in China (6%), moderate inadequacy in the USA (32%), and high levels of inadequacy for the Philippines (>90%).
Detailed dietary intake studies complement global monitoring of nutritional issues by WHO and the World Bank. They help to identify the foods and beverages most relevant to alleviate nutrient gaps and improve dietary intakes of toddlers and young children around the world.
References
1. World Health Organization. Malnutrition. 16 Feb 2018. https://www.who.int/newsroom/fact-sheets/detail/malnutrition (accessed Feb 2, 2020).
2. Ritchie H, Roser M: Our World in Data (https://ourworldindata.org/). Micronutrient Deficiency 2020 (https://ourworldindata.org/micronutrient-deficiency). Obesity 2020 (https://ourworldindata.org/obesity). Share of Children Who Are Stunted, 2016
(https://ourworldindata.org/grapher/child-stunting-ihme) (accessed Feb 3, 2020).
3. Huybrechts I, Aglago EK, Mullee A, et al: Global comparison of national individual food consumption surveys as a basis for health research and integration in national health surveillance programmes. Proc Nutr Soc 2017;76:549–567.
4. Rippin HL, Hutchinson J, Jewell J, et al: Child and adolescent nutrient intakes from current national dietary surveys of European populations. Nutr Res Rev 2018; 32:38–69.
5. Eldridge AL: FITS and KNHS overview: methodological challenges in dietary intake data collection among infants, toddlers and children in selected countries; in Henry CJ, Nicklas TA, Nicklaus S (eds): Nurturing a Health Generation of Children:
Research Gaps and Opportunities. Nestlé Nutrition Institute Workshop Series. Basel,
Karger, 2019, vol 91, pp 69–78.
6. Bueno MB, Fisberg RM, Maximino P, et al: Nutritional risk among Brazilian children 2–6 years old: a multicenter study. Nutrition 2013;29:405–410.
7. Chen C, Denney L, Zheng Y, et al: Nutrient intakes of infants and toddlers from maternal and child care centres in urban areas of China, based on one 24 h dietary recall. BMC Nutr 2015;1:23.
8. Sandjaja S, Budiman B, Harahap H, et al: Food consumption and nutritional and biochemical status of 0.5–12-year-old Indonesian children: the SEANUTS study. Br J Nutr 2013;110:S11–S20.
9. Denney L, Angeles-Agdeppa I, Capanzana MV: Nutrient intakes and food sources of Filipino infants, toddlers and young children are inadequate: findings from the National Nutrition Survey 2013. Nutrients 2018;10:1730.
10. Bailey RL, Catellier DJ, Jun S, et al: Total usual nutrient intakes of US children (under 48 months): findings from the Feeding Infants and Toddlers Study (FITS) 2016. J Nutr 2018;148:1557S–1566S.
11. Piernas C, Miles DR, Deming DM, et al: Estimating usual intakes mainly affects the micronutrient distribution among infants, toddlers and pre-schoolers from the 2012 Mexican National Health and Nutrition Survey. Public Health Nutr 2016;19:1017–1026.
12. Hilbig A, Drossard C, Kersting M, Alexy U: Nutrient adequacy and associated factors in a nationwide sample of German toddlers. J Pediatr Gastroenterol Nutr 2015;61:130–137.
13. Hilger J, Goerig T, Weber P, et al: Micronutrient intake in healthy toddlers: a multinational perspective. Nutrients 2015;7:6938–6955.
14. Keshabyants EE, Martinchik AN, Safronova AI, et al: The practice of feeding infants during the second and third years of life in Russia (analysis of the statistics of the Federal State Statistics Service Rosstat, 2013) (in Russian). Vopr Det Dietol (Pediatric Nutrition) 2017;15:11–17.
Abstract
Toddlers and young children need an adequate and diverse diet to provide all of the nutrients required for optimal growth and development. Unfortunately, inadequate intake of vitamins and minerals is still identified by the World Health Organization (WHO) as a major public health threat for young children. Organizations like the WHO and the World Bank focus primarily on iron, zinc, vitamin A, and iodine for children ≤5 years of age in low-income countries. In addition to the data from these organizations, individual-level food consumption surveys are needed to provide a fuller picture of food and nutrient intakes. Where studies are available, intakes of dietary fiber and vitamin D are generally below recommendations for toddlers and young children. Other nutrient gaps differ by country and are related to food availability and local dietary habits. For example, young children in the US regularly consume dairy products, and < 10% fall below recommendations for calcium intake compared to 2- to 4-year-old toddlers in the Philippines where dairy food consumption is low, and 66–84% fall below calcium recommendations. Dietary intake studies can help to identify the foods and beverages most relevant to alleviate nutrient gaps and improve dietary intakes of toddlers and young children around the world.
Introduction
Toddlers and young children need an adequate and diverse diet to provide all of the nutrients they require to support optimal growth and development. Unfortunately, undernutrition, growing rates of overweight and obesity, and inadequate intakes of vitamins and minerals are still identified as major public health threats for young children by the World Health Organization (WHO) [1]. For micronutrients, the WHO, UNICEF, and the World Bank focus primarily on iron, zinc, vitamin A, and iodine. Global monitoring shows that the combination of anemia rates, along with vitamin A deficiency and stunting, lead to an “alarmingly high” hidden hunger index in certain regions of the world, particularly sub-Saharan Africa and South Asia [2].
In addition to the global data from these organizations, individual-level food consumption surveys are needed to provide a fuller picture of food and nutrient intakes in different countries. However, these surveys are generally available in higher-income countries and are less common in low- and middle-income countries in regions such as Africa, Eastern Europe, and Southeast Asia [3]. Even among European countries with a food consumption survey, not all collect data on toddlers and young children [4]. National surveys in the US (National Health and Nutrition Examination Survey, NHANES) and Australia (National Nutrition and Physical Activity Survey, NNPAS) start only from the age of 2 years. Some national surveys also lack data on the full complement of nutrients required in the diet.
It is our aim, therefore, to evaluate what is known about the nutritional challenges and inadequacies facing toddlers across the world. With many sources of data, each one helps to build our knowledge by telling a different piece of the story. We will evaluate the information provided from each type of study and explore similarities and differences in the nutritional gaps of young children globally.
Monitoring Young Child Growth and Weight
The WHO, UNICEF, and the World Bank monitor several measures of growth and weight in children under 5 years of age globally [1, 5]. These measures help to identify and track problems of inadequate (wasting, stunting, and underweight) and excess nutrition (overweight and obesity), and because the measures are standardized, they also allow for comparisons across countries and over time. They are used by the WHO and UNICEF in collaboration with the Food and Agriculture Organization (FAO), the International Fund for Agricultural Development (IFAD), and the World Food Program (WFP) to monitor progress towards ending hunger, ensuring access to food, and eliminating all forms of malnutrition around the world [6]. Wasting refers to low weight for height, and usually results from recent and severe weight loss stemming from lack of food, diarrhea, or other infectious disease. Stunting is low height for age and is the result of chronic or recurring undernutrition associated with poverty, frequent illness, and inadequate feeding and care during early life. Underweight describes children who have a low weight for age. In addition to these issues of undernutrition, many children around the world are also facing excess body weight for height resulting in overweight or obesity due to overconsumption of energy relative to energy requirements.
Wasting affects 7.3% of the global young child population, or about 49.5 million
children under the age of 5 years [5]. More than 60% of wasted children worldwide live in Southern or Southeastern Asia (61.2%) and another 28.3% live in Africa. Stunting currently affects 21.9% of children less than 5 years of age (149 million children), and while this is lower than the 32.5% in 2000 [5], progress is still too slow to reach global nutrition targets of 14.6% by 2025 [6]. Overweight is only reported for North America, Asia, Africa, and Latin America, where it affects 5.9% of young children, amounting to 40.1 million [5]. Rates of overweight in these regions have increased from 4.9 to 5.9% since 2000. Overweight children are found across all income classifications, though the highest proportions are among middle-income countries [5]. These data highlight that
nutritional issues continue to affect our children (and families) globally; biggest problems of world hunger occur in sub-Saharan Africa and South Asia, and rates of overweight and obesity are growing in all regions and all age groups [6].
Micronutrient Deficiencies – The Big 4
Undernutrition is more than just an issue of energy intake – it also takes the form of inadequate intake of micronutrients (vitamins and minerals), leaving children at risk for deficiency diseases. The international agencies monitor certain vitamins and minerals in efforts to reduce the life-long consequences of low intakes of iron, zinc, vitamin A, and iodine [1]. Iron deficiency is the primary cause of anemia in young children, affecting both cognitive and physical development. Zinc intake is of concern, because deficiency limits childhood growth and decreases resistance to infection. Vitamin A intake and supplementation is monitored as vitamin A deficiency is the leading cause of childhood blindness globally. Iodine deficiency is the main cause of impaired cognitive development in children, and thus iodine deficiency and the impact of the universal salt iodization project are also scrutinized. Prevalence of anemia, defined as hemoglobin < 110 g/L at sea level, in children ≤5 years is highest in sub-Saharan Africa (59.9%) and South Asia (55.1%), whereas the rates are 15.3% in the European Union and 8.6% in North America [2]. The highest rates of vitamin A deficiency in young children are also found in sub-Saharan Africa and South Asia, where 60–70% are deficient [2]. Zinc deficiency is less prevalent, ranging from 15 to 50% across sub-Saharan Africa and
South Asia, and is generally < 5–10% for much of Europe, North America, Central
Asia, and Oceania [2]. Universal salt iodization began in the early 1990s to reduce the global burden of iodine deficiency. This program has now been implemented in 120 countries, and as a result of these efforts, approximately 71% of households globally now use iodized salt [7], greatly reducing iodine deficiency.
Dietary Diversity, Feeding Frequency, and Minimum Acceptable Diet Scores
Several indicators have been created by the WHO to assess feeding practices for
young children in regions at risk for inadequacies [8, 9]. A minimum dietary diversity score is calculated as a proxy measure for micronutrient adequacy of the diet. Minimum meal frequency is used to assess the likelihood of adequate energy intakes. These scores together are used to calculate a minimum acceptable diet score [10]. These indicators are collected as part of Demographic and Health Surveys (DHS), funded by the US Agency for International Development (USAID) and the Multiple Indicator Cluster Surveys (MICS) from UNICEF. Table 1 shows the scores for these indicators for children 12–23 months old across 7 UNICEF-defined regions [10].
Diet quality indicators show wide variability by geographic region and by country (Table 1). Overall, in the region of West and Central Africa, only 21.1% of children 12–23 months old reach minimum dietary diversity, and more than half of the countries in that region had less than 10% that met the minimum diversity score. In contrast, an average of 64.4% of children 12–23 months old in countries in Latin America and the Caribbean achieved the minimum diet diversity score. The average would have been > 68% without Haiti, which suffered the aftermath from Hurricane Matthew during their most recent survey (2016– 2017), resulting in only 19.8% achieving the minimum diet diversity score. The percentage of children 12–23 months of age achieving the minimum feeding frequency ranged from 41.3% in Eastern and Southern Africa to 74.8% in Eastern Europe and Central Asia. However, the overall scores for minimum acceptable diet were much lower, ranging from 11.2 in West and Central Africa to
not quantitative, so specific estimates of energy and nutrient intakes are not possible with these instruments.
Dietary Intake Surveys
When looking at the detailed dietary intake studies, we find wide ranges in energy intakes for 2- to 3-year-old children, with lower intakes in the Philippines (839 kcal/day) [18] and Indonesia (965 kcal/day) [19], and higher intakes in Brazil (1,650 kcal/day) [20], the USA (1,397 kcal/day) [23], and Mexico (1,367 kcal/day) [16]. Energy intakes were intermediate in children 2–3 years old from Russia (1,243 kcal/day) [17], Germany (1,075 kcal/day) [21], and China (1,189 kcal/ day) [13]. Energy intakes corresponded to higher rates of stunting in the Philippines, and higher rates of overweight and obesity in Brazil, North America, and Europe [2]. The distribution of energy from protein, fat, and carbohydrates also differs by country, with higher carbohydrate and lower fat intakes in Southeast Asia (Fig. 1).
Dietary fiber and vitamin D intakes are generally below recommendations for toddlers and young children, though vitamin D is not reported for every country (Table 2). Other nutrient gaps differ by country and are related to food availability and local dietary habits. For example, US children 2–4 years old regularly consume dairy products [24], and < 10% (6.4% of children 24–35 months old and 9.2% of those 36–47 months old) fall below recommendations for calcium intakes [23]. In contrast, in the Philippines and Indonesia, where consumption of dairy foods is rare, 66–84% of children 2–4 years old fall below calcium recommendations [18, 19]. For vitamin E, we see relatively low levels of inadequacy in China (6%), moderate inadequacy for the US (32%) and Germany
(43%), and high levels of inadequacy for the Philippines (> 90%). Iron intakes are
below recommendations for the majority of children in Indonesia (83%), the Philippines (75%), and Russia (64%), in contrast to those living in the USA, Mexico, and Brazil, where < 5% are below recommendations. In addition to nutrient intakes, detailed food consumption surveys can be analyzed to gain insights into dietary patterns, including amounts consumed from different food groups [24], food sources of energy and nutrients [14, 15, 18], or patterns of consumption, such as milk [17, 25] and beverage consumption [26, 27]. For example, we have been able to demonstrate the important role that fortified milk plays in the diet of young children in the Philippines [25] and
have modeled the impact of fortified milk in reaching dairy recommendations in China [28]. These types of analyses provide insights into why certain nutrients may be below (or above) recommended levels and help to better understand the impact of potential changes to dietary habits for children in different countries of the world.
Conclusions
National surveys provide population estimates of energy and nutrient intakes. By comparing with reference values, they can be used to identify the percentage of children and other population groups at risk for inadequate or excess intake. While many high-quality national surveys exist, there is still a gap in knowledge. For example, not all countries conduct quantitative national-level dietary intake studies. In those that do, not all studies include young children. Although food composition databases are constantly improving, there are discussions regarding the harmonization of nutrient reference standards [29] underway, and the European Food Safety Authority (EFSA) has put in place a common framework for conducting dietary intake surveys across Europe, called the EU MENU project [30]. However, there are still marked differences in the quality of food composition databases and methods used to conduct and analyze
comprehensive national nutrition surveys around the world. Improving the quality of food composition data, harmonizing nutrient reference standards, and using more consistent methodology will all help to improve our understanding of nutrient intakes and dietary patterns. High-quality dietary intake information for young children is still needed to help identify the foods and beverages most relevant to alleviate nutrient gaps and improve dietary intakes of toddlers and young children.
Using the data we have, we can see that child growth issues like stunting still affect approximately one-third of children < 5 years of age in Southern Asia, Central and Eastern Africa, and parts of Oceania, while overweight is rising in all regions of the world. Rates of anemia, vitamin A, and zinc deficiency are also highest in South Asia and Central African countries. The DHS and MICS show that fewer than 15% of children 12–23 months old in Central African countries and less than 30% in South Asian countries reach the minimum acceptable diet score. A deeper dive into the nutrient intakes from quantitative national nutrition surveys shows wide ranges in nutrient intakes for 2- to 3-year-old toddlers from Brazil, China, Indonesia, the Philippines, the USA, Mexico, Germany, and Russia. We saw generally low fiber and vitamin D intakes in the countries presented here, and wide variability in the percentage of young children with low intakes for vitamins A, C, and E, and for calcium, iron, and
zinc. Understanding dietary patterns can provide additional insight into the food-related causes of these inadequate intakes and help to define appropriate targets for improving nutrient intakes.
Conflict of Interest Statement
The authors, Alison L. Eldridge and Elizabeth A. Offord, are employees of Nestlé Research, Vers-chez-les-Blanc, Lausanne, Switzerland (Société des Produits Nestlé S.A.). Nestlé Research funded FITS in the USA, analysis of the MING study in China, and analysis of national nutrition survey data for Mexico, the Philippines, and Russia.
References
1. World Health Organization: Malnutrition. 16 Feb 2018. https://www.who.int/news-room/factsheets/ detail/malnutrition (accessed Feb 2, 2020).
2. Ritchie H, Roser M: Our World in Data (https:// ourworldindata.org/). Micronutrient Deficiency 2020 (https://ourworldindata.org/micronutrientdeficiency). Obesity 2020 (https://ourworldindata. org/obesity). Share of Children Who Are Stunted, 2016 (https://ourworldindata.org/ grapher/child-stunting-ihme) (accessed Feb 3, 2020).
3. Huybrechts I, Aglago EK, Mullee A, et al: Global comparison of national individual food consumption surveys as a basis for health research and integration in national health surveillance programmes. Proc Nutr Soc 2017; 76: 549–567.
4. Rippin HL, Hutchinson J, Jewell J, et al: Child and adolescent nutrient intakes from current national dietary surveys of European populations. Nutr Res Rev 2018; 32: 38–69.
5. United Nations Children’s Fund (UNICEF), World Health Organization, the World Bank: Levels and Trends in Child Malnutrition: Key Findings of the 2019 Edition of the Joint Child Malnutrition Estimates. Geneva, World Health Organization, 2019.
6. FAO, IFAD, UNICEF, WFP, WHO: The State of Food Security and Nutrition in the World 2019. Safeguarding against Economic Slowdowns and
Downturns. Rome, FAO, 2019.
7. World Health Organization: Guideline: Fortification of Food-Grade Salt with Iodine for the Prevention and Control of Iodine Deficiency Disorders. Geneva, WHO, 2014.
8. World Health Organization: Global Nutrition Monitoring Framework: Operational Guidance for Tracking Progress in Meeting Targets for 2025. Geneva, World Health Organization, 2017.
9. Kennedy G, Ballard T, Dop M: Guidelines for Measuring Household and Individual Dietary Diversity. Rome, Nutrition and Consumer Protection Division, FAO, 2013.
10. United Nations Children’s Fund, Division of Data, Analysis, Planning, and Monitoring: Global UNICEF Global Databases: Infant and Young Child Feeding: Minimum Acceptable Diet, Minimum Diet Diversity, Minimum Meal Frequency. New York, UNICEF, 2019.
11. Eldridge AL: FITS and KNHS overview: methodological challenges in dietary intake data collection among infants, toddlers and children in selected countries; in Henry CJ, Nicklas TA, Nicklaus S (eds): Nurturing a Health Generation of Children: Research Gaps and Opportunities. Nestlé Nutrition Institute Workshop Series. Basel, Karger, 2019, vol 91, pp 69–78.
12. Schaafsma A, Deurenberg P, Calame W, et al, SEANUTS Study Group: Design of the South East Asian Nutrition Survey (SEANUTS): a four-country multistage cluster design study. Br J Nutr 2013; 110:S2–S10.
13. Chen C, Denney L, Zheng Y, et al: Nutrient intakes of infants and toddlers from maternal and child care centres in urban areas of China, based on one 24 h dietary recall. BMC Nutr 2015; 1: 23.
14. Wang H, Denney L, Zheng Y, et al: Food sources of energy and nutrients in the diets of infants and toddlers in urban areas of China, based on one 24-hour dietary recall. BMC Nutr 2015; 1: 19.
15. Denney L, Afeiche MC, Eldridge AL, Villalpando- Carrion S: Food sources of energy and nutrients in infants, toddlers, and young children from the Mexican National Health and Nutrition Survey 2012. Nutrients 2017; 9: 494.
16. Piernas C, Miles DR, Deming DM, et al: Estimating usual intakes mainly affects the micronutrient distribution among infants, toddlers and preschoolers from the 2012 Mexican National Health and Nutrition Survey. Public Health Nutr 2016; 19: 1017–1026.
17. Keshabyants EE, Martinchik AN, Safronova AI, et al: The practice of feeding infants during the second and third years of life in Russia (analysis of the statistics of the Federal State Statistics Service Rosstat, 2013) (in Russian). Vopr Det Dietol (Pediatric
Nutrition) 2017; 15: 11–17.
18. Denney L, Angeles-Agdeppa I, Capanzana MV: Nutrient intakes and food sources of Filipino infants, toddlers and young children are inadequate: findings from the National Nutrition Survey 2013. Nutrients 2018; 10: 1730.
19. Sandjaja S, Budiman B, Harahap H, et al: Food consumption and nutritional and biochemical status of 0.5–12-year-old Indonesian children: the SEANUTS study. Br J Nutr 2013; 110:S11– S20.
20. Bueno MB, Fisberg RM, Maximino P, et al: Nutritional risk among Brazilian children 2–6 years old: a multicenter study. Nutrition 2013; 29: 405– 410.
21. Hilbig A, Drossard C, Kersting M, Alexy U: Nutrient adequacy and associated factors in a nationwide sample of German toddlers. J Pediatr Gastroenterol Nutr 2015; 61: 130–137.
22. Hilger J, Goerig T, Weber P, et al: Micronutrient intake in healthy toddlers: a multinational perspective. Nutrients 2015; 7: 6938–6955.
23. Bailey RL, Catellier DJ, Jun S, et al: Total usual nutrient intakes of US children (under 48 months): findings from the Feeding Infants and Toddlers Study (FITS) 2016. J Nutr 2018; 148: 1557S–1566S.
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