Malaysian journal of nutrition | 2021
Malnutrition and its risk factors among children and adolescents with intellectual disability (ID) in Asian countries: A scoping review
Abstract
Introduction: Children with intellectual disability (ID) have higher probability of experiencing poor health status due to their limited ability to understand and assess information about nutrition and health. Malnutrition remains a significant health problem as it is prevalent among both typically developing and disabled children. This scoping review aims to discuss the prevalence of malnutrition among children and adolescents with ID in Asian countries. Methods: The review was based on the PRISMA-ScR method. A systematic electronic search was conducted using databases namely PUBMED, Science Direct, Scopus, and Google Scholar for articles published from 2006-2019, written in English and involved studies in Asian countries. Results: A total of 255,100 article’s titles were identified and only 17 articles that met the inclusion criteria were included for further analysis. The findings revealed that the range of prevalence for underweight was 5.7%-76.3% and 28.9%-45.0% for stunting. The prevalence estimated for overweight was 3.9%-46.6%, while obesity was 1.6%26.6%. The body mass index values ranged from 17.4±4.3kg/m2-23.0±6.3kg/m2. There were several risk factors related to malnutrition such as co-morbidity factors, behavioural factors, and parental factors. Conclusion: This review demonstrated concern regarding the prevalence of malnutrition among children and adolescents with ID, which is high in certain Asian countries. It was varied and thus difficult to compare due to different reference standards and definitions used for malnutrition. Establishing nutrition and health-related intervention programmes can help to prevent further rise in the prevalence of malnutrition in this group. Keyword: Intellectual disability, malnutrition, overweight, obesity, underweight INTRODUCTION Intellectual disability (ID) is referred as a condition characterised by impaired intelligence and social functioning which begins before adulthood and affects normal development (WHO, 2020). Based on the American Association on Intellectual and Developmental Disabilities (AAIDD), intellectual disability, which was previously known as mental retardation, is defined as “the presence of three coexisting features, namely significant sub-average intellectual functioning, deficits or Siti Fathiah M, Soo KL & Divya V 28 impairments in adaptive skills, and onset before 18 years of age” (Shea, 2012). The United Nations Children’s Fund (UNICEF) (2018) estimated that there are at least 93 million children with disabilities in the world, and this statistic could be higher due to unreported data. UNICEF further stated that 1 in 20 children aged 14 years or younger lives with moderate to severe disabilities. However, the data included all types of disabilities, not differentiated either by intellectual, physical or other disabilities. A meta-analysis found that the prevalence of ID among children and adolescents was 1.83% and the femaleto-male ratio varied between 0.4 and 1.0 (Maulik et al., 2011). Recently, McKenzie et al. (2016), who extended Maulik et al. (2011)’s work, reported that the prevalence of ID for all age groups was estimated to be 0.05%-1.55%. Some ID children would have comorbid conditions such as autism, attention deficit disorder (ADHD), Down syndrome, epilepsy, and anxiety (Eisenhower, Baker, & Blacher, 2005; Jauhari et al., 2012; Krause et al., 2016). They have a higher probability of experiencing poor health status as compared to those without ID due to their limited ability to comprehend and assess information about nutrition and health. Hence, poor health status would expose them to the risk of getting communicable or non-communicable diseases as a secondary health condition (Bellamy, 2016). Nutritional status is an important indicator to determine the overall health status and wellbeing of children and adolescents with ID as these groups are vulnerable to suffer from malnutrition (under or over-nutrition). The World Health Organization (WHO) (2020) defines malnutrition as “deficiencies, excesses, or imbalances in a person’s intake of energy and/or nutrients; referring to three groups of conditions which are undernutrition, macronutrient-related malnutrition, and overweight/obesity”. Malnutrition in this review will focus on undernutrition (wasting, stunting, and underweight) and overnutrition (overweight and obesity). The Global Nutritional Report (2020) reported a declining prevalence in underweight from 39.5% in the year 2000 to 33.7% in the year 2016 among children and adolescents (aged 5-19 years) in Asian countries. Meanwhile, overweight and obesity among children and adolescents showed a rising trend from 2000-2016, with a prevalence of 7.0%-17.3% and 1.7%-6.5%, respectively. Even though the prevalence of underweight has decreased, it remains a problem because the decline is too slow, while overweight and obesity is rising rapidly. Undernutrition among children and adolescents with ID may result due to a lack in nutritious food intakes following their dependency on feeding and food preparation. This situation might worsen when they lose weight due to other risk factors such as multiple health conditions, frequent infections, as well as limited access to quality health care. A systematic review reported that disabled children are three times more likely to be underweight and twice as likely to have wasting and stunting as compared to normal children (Humenixon & Kuper, 2018). On the other hand, several studies found that children with disabilities had higher prevalence of overweight and obesity compared to children without disability (Bandini et al., 2015; Ogwu, 2012). A systematic review on overnutrition revealed that adolescents with ID have more risk of having overweight-obesity (1.54 times) and obesity (1.80 times) than typically developing adolescents (Maïano et al., 2016). The possible risk factors contributing to the rising level of overweight and obesity among children and adolescents with ID are age, gender, Malnutrition among children & adolescents with ID in Asia 29 sedentary behaviour, higher intakes of energy-dense foods, co-morbidities, and genetic disorders (Krause et al., 2016; Segal et al., 2016). Disabled children who are obese will be vulnerable to remain obese during adulthood and are prone to get other health problems such as diabetes, hypertension, and cardiovascular disease (Raghi et al., 2016; Rimmer et al., 2010). Thus, these evidences suggest that malnutrition remains one of the significant health problems among children and adolescents as it is not only prevalent among typically developing children, but also among disabled children. To our knowledge, no published review article has explored the existence of malnutrition among ID children and adolescents in Asian countries. Understanding the current situation and trends on malnutrition among Asian children and adolescents with ID will provide useful information to assist researchers and health professionals in identifying priority health programmes for the prevention and care of this vulnerable group. This scoping review aims to review the prevalence of malnutrition among children and adolescents with ID in Asian countries. MATERIALS AND METHODS Sources of information and search strategy The present study is a scoping review that was designed based on the “Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR)” method (Tricco et al., 2018). A systematic electronic search was conducted using four databases, namely PUBMED, Science Direct, Scopus, and Google Scholar to source for research papers published from 2006-2019 that were written in English. In addition, a hand search was carried out using the reference lists of relevant articles and previous literature reviews on related topics. The keywords that were used in the database machines comprised of malnutrition, nutritional status, underweight, obesity, overweight, body weight status, body mass index, children, adolescent, intellectual disability, and mental retardation. The search strategies included all possible combinations of key search terms which were: (a) (malnutrition) AND children OR adolescent AND (intellectual disability OR mental retardation), (b) (overweight OR obesity OR underweight) AND children OR adolescent AND (intellectual disability OR mental retardation) (c) body weight status AND children OR adolescent AND (intellectual disability OR mental retardation) and (d) body mass index AND children OR adolescent AND (intellectual disability OR mental retardation). Inclusion criteria Research articles that met these specific inclusion criteria were considered eligible for this review. Firstly, the study participants were presented with ID. Studies based on mixed samples of participants presented with multiple disabilities were also considered eligible if specific data regarding the prevalence of underweight, overweight, or obesity were available for children and/or adolescents with ID. Secondly, the age of the study participants had to be 19 years old and below, which consisted of children and/or adolescents. Studies on a single sample (children or adolescents) or mixed samples (children and adolescents) were considered eligible if specific data on malnutrition were available. Thirdly, this review only included original research articles of a cross-sectional study or survey that were written by the researchers who conducted the study. Lastly, only Siti Fathiah M, Soo KL & Divya V 30 studies within 48 countries in the Asian continent were included. Study selection and data charting The articles were selected based on the PRISMA-ScR method (Tricco et al., 2018). The study selection was based on the objectives of the study which focused on malnutrition of children and adolescents with ID in Asian countries. The researchers eliminated irrelevant articles based on the inclusion and exclusion criteria, as well as those that did not an