Zenaida Velasco , RND, MAP
Introduction
Malnutrition refers to incorrect nutritional or energy intake largely due to deficiencies, excesses, or imbalances in the diet. Undernutrition, which includes stunting (low height-for-weight), wasting (low weight-for-height), underweight (low weight-for-age), and micronutrient deficiencies, is one umbrella term under malnutrition. The other part is overweight, obesity, and diet-related noncommunicable diseases (NCDs), such as heart disease, diabetes, and cancer. It is important to note here that an obese or overweight patient can still be malnourished.
Worldwide, malnutrition is common not just in children but adults as well. According to the World Health Organization (WHO), there are around 1.9 billion overweight and 462 million underweight adults worldwide.1 In children below 5 years of age, around 159 million are stunted, around 38.9 million children are overweight or obese, and 45 million children are wasted.2,3
Malnutrition in the Philippines
In the Philippines, there is a 37.2% prevalence of obesity and overweight according to the Expanded National Nutritional Survey (ENNS) conducted by the Food and Nutrition Research Institute in 2018. This is a 6.1% increase from the 2015 survey.4
Figure 1. Trends in the prevalence of overweight and obesity among adults 20 years and above (DOST-FNRI, 2018)
Among Filipino adolescents (aged >10-19 years old), 26.3% are stunted and 11.3% are wasted. The prevalence of stunting has gone down a lot through the years, but wasting has increased slightly.
Figure 2. Trends in the prevalence of stunting and wasting among adolescents 10-19 years old (DOST-FNRI, 2018)
There is 30.3% prevalence of stunting, 19.1% prevalence of underweight, and 5.6% prevalence of wasting in children under 5 years old according to the latest ENNS data. Furthermore, obesity in children aged 2-5 years old has a 4% prevalence. The first three data points have gone down slightly through the years. On the other hand, the prevalence of overweight in children aged 2-5 years old has risen.
Figure 3. Trends in the prevalence of malnutrition among children under 5 years (0-59 months) (DOST-FNRI, 2018)
Mothers who are malnourished have poor pregnancy outcomes for both herself and her baby. The child is at risk of being born prematurely or having low birth weight. Stunting is the main indicator of the extent of growth failure in the first 1,000 days of life. Stunting in early life has irreversible, adverse functional consequences on the child including poor cognitive skills and academic performance, low adult salary, and lower productivity. Children with poor nutritional status are at risk of premature death due to susceptibility to infection and slower recovery from illness.
Indeed, children with a slow start in life tend to lag further behind in performance at school and eventually as adults and at work. Children who are undernourished often fail to reach their optimum height and weight, thus holding back their performance. They also develop lower IQ and are more prone to infections, and these can lead to low academic performance and frequent absenteeism. While obese children are at risk of developing noncommunicable diseases including high blood pressure, high cholesterol, cardiovascular diseases, type 2 diabetes, asthma, and sleep apnea.5
The First 1,000 Days: “Malnutrisyon patuloy na labanan, First 1,000 days tutukan!”
There is a need to provide good nutrition as early as possible to the child. ‘As early as possible’ seems vague, thus, the National Nutritional Council has unveiled “Malnutrisyon patuloy na labanan, First 1,000 days tutukan!”, the 2021 Nutrition Month theme.6 The theme focuses on the importance of good nutrition in the first 1,000 days of life, starting from the womb until the child’s second birthday, with the aim of warding off stunting, obesity, and other manifestations of malnutrition. Known as a “golden window of opportunity”, the first 1,000 days of life is the best opportunity to prevent malnutrition and for optimal physical and mental development. Proper nutrition during the first 1,000 days sets up the child to be more resistant to infections by strengthening the immune system, supports proper brain development, thereby making them healthier and more resilient in future life stages.
In promoting the first 1,000 days, the mother should always be well-nourished, since she is the primary source of nutrition in this early stage. If the mother is underweight and consumes unhealthy foods, she may not be able to properly nourish her child. Further, it is important to regularly consult with her doctor and a Registered Nutritionist-Dietitian (RND) regarding her and her child’s nutritional needs. The father’s care, including emotional support for the mother and the unborn child, will not only create a strong bond but will also make this difficult time more bearable.
Investing time and effort in the first 1,000 days will ensure a bright future for the child. It is also important to recognize during this time the importance of government-subsidized healthcare and wise financial allocation towards proper nutrition. Nations should focus on more resources and craft policies towards supporting mothers and children, as this can be seen as a return in investment in the coming decades. On the 29th of November 2018, Republic Act 11148 or the “Kalusugan at Nutrisyon ng Mag-Nanay Act” was signed into law. This law helps provide the much-needed nutritional support for the mother and child during the first 1,000 days.7 Further, according to a study published in “The Economic Consequences of Undernutrition in the Philippines: A Damage Assessment report” in 2018, the Philippines will continue to suffer economic losses estimated at $4.5 billion annually if undernutrition is not addressed. Another study, entitled "Business Case for Nutrition Investment in the Philippines", proposes that affordable and equity-focused nutrition will counteract the economic burden due to undernutrition. In numbers, a $1 investment in nutrition will reap the economy $12 (1 USD = 49.65 PHP).
Nutritional needs during the first 1,000 days
Two of the most crucial among micronutrients in the first 1,000 days are iron and folic acid. During pregnancy, the mother has increased need for iron due to the concomitant iron demand of pregnancy. Moreover, as she progresses through trimesters, her need for iron further increases. According to the 2018 Philippine Dietary Reference Intake (PDRI) of the Food and Nutrition Research Institute (FNRI), a mother has to increase her daily iron intake by 10 milligrams during pregnancy and by 2 milligrams when she is lactating. Low iron levels during pregnancy can lead to poor birth outcomes, such as low birth weight and preterm birth.8
Folic acid, on the other hand, is important for embryonic development. It helps ensure that the infant does not suffer physical birth defects9, especially those in the neural tube, and promotes the development of red blood cells. According to PDRI 2018, a pregnant mother should take an additional 200 micrograms of dietary folate equivalent (µgDFE) daily.10
Aside from iron and folic acid, there are other nutrients that are needed by the mother during pregnancy and breastfeeding. Meeting the adequate energy and nutrient intakes of a pregnant and lactating mother is not an easy feat. The following is a comprehensive chart of nutritional recommendations.
Table 1. Important nutrients during pregnancy and lactation
| Nutrient | Functions | Consequences of Deficiency | Recommended Nutrient Intake (PDRI 2015) | Common Food Sources |
|---|---|---|---|---|
| Vitamin A | Bone growth, reproduction, cell division, immunity, cell differentiation | Clinical: Night blindness; total blindness Subclinical: May increase risk for respiratory and diarrheal infections, decrease growth rate, slow bone development, and decrease likelihood of survival from serious illness | Pregnancy: +300 μgRE on top of RNI Lactation: *** +400 μgRE on top of RNI | Liver, milk, eggs, green leafy vegetables, orange and yellow vegetables, dairy products |
| Vitamin C | Antioxidant; biosynthesis of connective tissue components (collagen, elastin, fibronectin, proteoglycans, bone matrix, and elastin-associated fibrillin), carnitine, and neurotransmitters | Scurvy (involves deterioration of elastic tissue and can include follicular hyperkeratosis, petechiae, ecchymoses, coiled hairs, inflamed and bleeding gums, perifollicular hemorrhages, joint effusions, arthralgia, and impaired wound healing), dyspnea, edema, Sjogren syndrome, weakness, fatigue, depression | Pregnancy: *** +10 mg on top of RNI Lactation:*** +35 mg on top of | Fruits and vegetables |
| Vitamin B1 (Thiamine) | Coenzyme in the metabolism of carbohydrates and branched-chain amino acids | Anorexia; weight loss; mental changes such as apathy, decrease in short-term memory, confusion, and irritability; muscle weakness; cardiomegaly; beriberi (polyneuritis, rarely congestive heart failure); Wernicke-Korsakoff syndrome | Pregnancy: +0.3 mg on top of RNI Lactation: +0.2 mg on top of RNI | Whole grains and meat |
| Vitamin B2 (Riboflavin) | Coenzyme in numerous redox reactions | Sorethroat, hyperemia and edema of pharyngeal and oral mucous membranes; cheilosis; angular stomatitis; glossitis (magenta tongue); seborrheic dermatitis; normochromic, normocytic anemia | Pregancy: +0.7 mg on top of RNI Lactation:*** +0.6 mg on top of RNI | Eggs, organ meats, lean meats, and milk |
| Vitamin B3 (Nilacin) | functions | Pellagra (pigmented rash; "sunburned" appearance; vomiting, constipation or diarrhea; bright red tongue; neruological symptoms, including depression, apathy, headache, fatigue, and loss of memory | Pregnancy: +4 mgNE on top og RNI Lactation: +3 mgNE on top of RNI | Poultry, beef, nuts, legumes, and grains |
| Vitamin B5 (Pantothenic acid) | Component of coenzyme A; cofactor and acul group carrie for many enzymatic processes, and acyl carrier protein, a component of the fatty acid synthase complex | Extremely rare; irritability and restlessness; fatigue; apathy; malaise; sleep disturbances; gastro-intestinal complaints such as nausea, vomiting, and abdominal cramps; neurobiological symptoms such as numbness, paresthesias, muscle cramps, staggering gait, hypoglycemia | Pregnancy: 6.0 mg Lactation: 7.0 mg | Most animal- and plant-based foods |
| Vitamin B6 (Pyridoxine) | Coenzyme in the metabolism of carbohydrates and branched-chain amino acids, glycogen, and sphingoid bases | Seborrheic dermatitis. microcytic anemia, epileptiform convulsions, electroencephalographic abnormalities, glossitis, depression and confusion, weakened immune function | Pregnancy: +0.6 mg on top of RNI Lactation: +0.7 mg on top of RNI | Beef liver, potatoes and other starchy vegetables, fruit |
| Vitamin B12 (Cobalamin) | Cofactor for methionine synthase and L-methyl-malonyl-CoA mutase; essential for normal blood formation and neurologic function | Pernicious anemia; neurologic mainfestations (sensory disturbances in the extremities; motor disturbances, including abnormalities of gait), cognitive changes (loss of concentration, memory loss, disorientation and frank dementia); visual disturbances, insomia, impotency, and impaired bowel and bladder control | Pregnancy: +0.2 μg on top of RNI Lactation: +0.5 μg on top of RNI | Foods sourced from animals |
| Folate | Folate coenzymes are involved in DNA synthesis; amino acid interconversion including conversion of homocysteine of methionine; single-carbon metabolism; methylation reactions | Hypersegmented neutrophils, macrocytic anemia (weakness, fatigue, difficulty concentrating, irritability, headache, palpitations, shortness of breath), elevated homocysteine, increased risk of neural tube defects in offspring of women deficient during the periconceptual period | Pregancy: +200 μgDFE on top of RNI Lactation:*** +150 μgDFE on top of RNI | Green leafy vegetables, fruits, nuts, beans, peas, seafood, eggs, dairy products, meat, poultry, and grains |
| Choline | Choline helps the body synthesize phosphatidyl-choline and sphingomyelin, as well as produce acetylcholine, an important neurotransmitter for memory, mood, muscle control, and other brain and nervous system functions. Moreover, choline assists in modulating gene expression, cell membrane signaling, lipid transport and metabolism, and early brain development** | Muscle damage, liver damage, and nonalcoholic fatty liver disease** | Precnancy: 3000 mg | Meat, poultry, dairy products, eggs, cruciferous vegetables, beans, nuts, seeds, whole grains |
| Calcium | Component of teeth and bones; mediates vascular contraction and vasodilation, muscle contraction, nerve transmission, and glandular secretion | Reduced bone mass and osteoporosis | Pregnancy: +50 mg on top of RNI, during third trimester only Lactation: None | Milk, cheese, yogurt, vegetables (e.g., broccoli and Chinese cabbage) |
| Phosphorus | Component of most biological membranes and nucleotides and nucleic acids; buffering of acid of alkali excesses; temporary storage and transfer of the energy derived from metabolic fuels; activation of many catalytic proteins through phosphorylation | Anoxeria, anemia, muscle weakness, bone pain, rickets, and osteomalacia, general debility; may be seen in persons recovering from alcoholic bouts; in diabetic keto-acidosis; in refeeding with calorie-rich sources without paying attention to phosphorus needs; & with AL-containing antacids | Pregnancy/Lactation: None | Dairy products, meats and poultry, eggs, nuts, legumes, vegetables, and grains |
| Magnesium | Required cofactor for more than 300 enzymes, including ones involved in anaerobic and aerobic energy generation, glycolysis, and oxidative phosphorylation; DNA and RNA synthesis; activation of adenylate cyclase; sodium; potassium-ATPase activity; has a calcium channel-blocking effect | Hypocalcemia; neuromuscular hyperexcitability & latent tetany; insulin resistance and impaired insulin secretion | Pregnancy: None Lactation: +50 mg on top of RNI | Green leafy vegetables, legumes, nuts, beans, seeds, and whole grains |
| Potassium | Neural transmission; muscle contraction, vascular tone | Cardiac arrhythmias; muscle weakness; leg discomfort; extreme thirst, frequent urination; confusionl glucose intolerance, increased blood pressure, increased salt sensitivity, increased risk for kidney stones, increased bone turnover | Pregnancy/Lactation: None | Fruits and vegetables, legumes, potatoes, meats, yogurt, milk, nuts, whole-wheat flour, brown rice |
| Iron | Component of enzymes necessary for oxidative metabolism; heme proteins (hemoglobin, myoglobin, cytochromes); participates in electron transfer | Impaired physical work performance, development delay, cognitive impairment, anemia | Pregnancy: +10 mg on top of RNI, from supplements Lactation:*** +2 mg on top of | Lean meat, seafood, poultry, and beans |
| Zinc | Component of enzymes (RNA polymerase, alkaline phosphatase); structural role for some enzymes and in protein folding: antioxidant function as part of zine-copper superoxide dismutase | Growth retardation, hair loss, diarrhea, delayed sexual maturation and impotence, eye and skin lesions, loss of appetite, delayed wound healing | Pregnancy: +5.1 mg on top of RNI Lactation: +7.0 mg on top of | Red meat, poultry, oysters, beans, nuts, whole grains, and dairy products |
| Copper | Component of metalloenzymes (oxidases; e.g., monoamine oxidase; lysyl oxidase used foro collagen and elastin production; cytochrome c oxidase; dopamine β mono-oxygenase); part of zinc-copper SOD | Defects in connective tissue anemia; immune and cardiac dysfunction | Pregnancy: 1,000 μg Lactation: 1,300 μg | Seeds and nuts, organ meats, whole-grain products, and chocolate |
| Chromium | Potentiates insulin action, mobilizes the gluclose transporter GLUT4 to the plasma membrane; enhances tyrosine phosholyration of the insulin receptor | Rare; found in patients on TPN prior to inclusion of Cr+3; symptoms included weight loss, neuropathy, and impaired glucose tolerance | Pregnancy: 50 μg Lactation: 45 μg | Grain products, fruits, vegetables, nuts, spices |
| Selenium | Defense against oxidative stress, regulation of thyroid hormone action, and regultion of the redox status of vitamin C and other molecules through selenoproteins; e.g., oxidant defense enzymes like peroxidase; iodothyronine deiodinases | Keshan disease (cardiomyopathy in pediatric population); skeletal muscle disorders manifested by muscle pain fatigue, promixal weakness, and serum creatine kinase (CK) elevation | Pregnancy: +4 μg on top of RNI Lactation: +9 μg on top of | Organ meats, eggs |
| Iodine | Component of the thyroid hormones thyroxine (T4) and triiodothyronine (T3) | Intellectual disability, hypothyroidism, and varying degrees of other growth and developmental abnormalities | Pregancy: +100 μg on top of RNI Lactation: | Iodized salt, eggs, and dairy products |
| Manganese | Component of metalloenzymes (arginase, manganese superoxide dismutase, pyruvate carboxylase) | Dermatitis, hypocholesterolmia | Pregnancy: 2 mg Lactation: 2.6 mg | Whole grains, clams, oysters, mussles, nuts, soybeans and other legumes, rice, leafy vegetables, coffee, tea, and many spices |
| Molybdenum | Component of sulfite oxidase, xanthine oxidase, aldehyde oxidase, enzymes involved in catabolism of sulfur-containing amino acids, purines, and pyridines | Rare; initially seen in patients on TPN, before addition of MO to standard TPN regimes; resulted in tachycardia, headache, night blindness, low serum uric acid | Adults (ages 19+): 45 μg Infants/children: 0-6 months:2 μg 7-12 months: 3 μg 1-3 years: 17 μg | Legumes, whole grains. nuts, beef liver |
Note: From Micronutrients in health and disease: Nutrition guide for clinicians by Nutrition Guide for Clinicians, 2020.11 Items marked ‘*’ are from Institute of Medicine (IOM) wherein no RDA for vitamins in this age group. Instead, an Adequate Intake (AI) is used; items marked ‘**’ are sourced from Dietary Supplement Fact Sheets by National Institutes of Health12; items marked ‘****’ are from the Nutrition module: 2. nutrients and their sources by The Open University, 2017.13
Role of Nutritionist-Dietitians in the First 1,000 Days
The role of RNDs in the first 1,000 days is crucial. Knowing that weight is always an issue during pregnancy, RNDs should come in as early as pre-conception. Even before getting pregnant, the mother’s pre-pregnancy weight should be within the normal Body Mass Index of 18.5 to 24.9. If the mother is overweight, she will be advised to lose weight before getting pregnant, and/or gain weight when necessary.
Pregnant mothers should also keep from overeating since they are not really eating for two. Obesity during pregnancy can lead to a host of complications, such as poor birth outcomes, cesarean section delivery and even postnatal depression. RNDs should draw the limits of weight gain during pregnancy to ensure optimal outcomes.
The first 1,000 days of life seem like a lot of days to count, especially from a mother who experiences physical, emotional, and social adjustments; however, it is worthwhile to note that the role of the father during pregnancy and after the baby is born should be just as important. Fathers should be supportive to their pregnant life partners by making sure that the mother is not undergoing a lot of stress. Bringing up the child is a shared responsibility where the father should play an active role in feeding and in taking care of the child. Both parents can provide a blanket of security for a growing child.
Definitely, parents must keep the communication lines open with their doctors and RNDs. The collaborative efforts of both the doctor and the RNDs will ensure that the child attains physical and mental development to prepare him for a healthy and productive future.
Message from Ms. Velasco to Nutritionist-Dietitians
"We have to understand the roles of specific macronutrients and micronutrients that can support the physical and mental development of the mother and child through Good Nutrition. Let’s articulate the very famous ‘MoVABa’, which stands for Moderation, Variety, and Balance. Moreover, let us be a champion to combat malnutrition in the first 1,000 days. Look at it from a wider spectrum: whether undernutrition or overnutrition, it poses health risks even in later years.
No two persons are alike, thus, nutrition plans should be personalized and tailored fit for our clients, given the fact that genetics and other environmental factors may differ among individuals. Finally, it pays to apply evidence-based practice; thus RNDs should be updated on the current, effective nutrition interventions by attending NDAP’s webinars to enhance their knowledge and competencies.”
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