The objective of the present work was to study the impact of the double burden of malnutrition on gross motor development among Ecuadorian infants. Our findings indicate that independently from age, sex and other socio-economic factors, chronic undernutrition, but not overweight/obesity is related to delayed acquisition of gross motor milestones. For instance, we found that among infants with chronic undernutrition, the odds of sitting without support, crawling and walking without support was lower than that among infants with normal HAZ. Surprisingly, we also observed that obese infants had higher odds of sitting without support in comparison to children with normal BAZ.
4.1 The double burden of malnutrition among infants in Ecuador
The Sustainable Development Goals adopted by the members of the United Nations, emphasize the need of ending hunger and all forms of malnutrition as well as achieving food security by 2030 (23). Although some progress has been made, the double burden of malnutrition is still a matter of concern in Ecuador (11, 24). In fact, our data indicate that in 2018, one fifth of Ecuadorian infants younger than 24 months suffered from chronic undernutrition and another 20% obesity. Strikingly, considering those who were at risk of chronic undernutrition or overweight, only half of Ecuadorian infants younger than 24 months achieved normal growing standards in 2018. These rates are not only alarmingly higher than those of other countries with similar income in the region, but also far away from achieving the second goal of the 2030 Agenda for Sustainable Development (25).
The emergence of obesity in a society where the problem of undernutrition has not yet been solved, is a stark indication of how a large majority of Ecuadoreans are poorly protected from the multiple factors driving malnutrition in all its forms (13). In the case of infants, their vulnerability might arise from intergenerational transmission of risk of malnutrition within a context of socio-economic disadvantage and gender inequalities (13, 26). For example, household food insecurity, a condition related to social inequalities that limits access to a nutritions and safe diet, has been consistently associated to both undernutrition and overweight/obesity (26). Moreover, there are challenges in Ecuador related to infant malnutrition that have been poorly addressed by policy makers including, poor promotion of exclusive breastfeeding and insufficient marketing regulation for infant formula (27).
4.2 Chronic undernutrition and gross motor development
Nutrition during critical phases of development has long-term effects on organ size, structure and function and thus, it is a key player in infant cognitive and physical development. It is not surprisingly then, that we and others have found that infants with chronic undernutrition are less likely to sit without support, crawl or walking alone compared to infants without undernutrition of the same age (8–10, 15–17). Moreover, since achievement of gross motor abilities requires integrity of the nervous system, the delay we observed in chronically undernourished infants might be the consequence of suboptimal brain development.
It is not well understood how nutrients contribute to brain development or behaviour; however, there are two possible mechanisms (28). On one hand, nutrients might support structural and functional development of the brain; on the other, they might enhance health and thus interaction with the environment, which stimulates brain development (28). Though all nutrients are important for brain development, there some that are particularly important during early life, specially when their deficiency coincides with critical or sensitive periods (29). Macro and micronutrients critical for brain development and whose deficiency is highly prevalent among infants growing in low/middle income countries include, protein, long-chain polyunsaturated fatty acids, iron, zinc, and iodine (12).
Although severe delays in achievement of gross motor milestones in infancy are generally prodromal symptoms of intellectual disability, the importance of motor development is not limited to children with disabilities (30, 31). For example, among normally developing infants, achieving a gross motor milestone later than peers has unfavourable effects on adaptive skills and cognitive performance in childhood (31). Furthermore, the detrimental consequences of undernutrition on brain development might not only have an immediate effect on infant development, but cause global dysfunction on the person as a child and adult (29, 32). Along this line, undernourishment during infancy has ben shown to negatively impact academic and work productivity as well as adult mental health (10).
4.3 Excess weight and gross motor development
Since we found that obese infants were more likely to sit without support in comparison to infants with normal BAZ of the same age, it seems that our results somehow contradict those of previous studies, which in general found excess of weight to be detrimental (14, 33, 34). Further, in contrast to what has been previously described we did not find evidence to support an association between delayed gross motor development and overweight/obesity (33, 34). However, it is noteworthy that besides sitting without support, obese/overweight infants were not more likely than their peers with normal weight to acquire earlier other gross motor milestones. Together these observations suggest that the effects of malnutrition related to excess of weight could be less evident during this stage of development, because it is not related to a massive deprivation of nutrients as in the case of chronic undernourishment (29, 35).
4.3 Implications, strengths and limitations
Our findings suggest a harmful influence of malnourishment on infant development. More specifically, we found that chronic undernourishment but not overweight/obesity is related to delayed gross motor development in Ecuadorian infants younger than 24 months of age. Considering the high prevalence of malnutrition among Ecuadorian infants and its deleterious consequences, a huge impact on the general health and productivity of the population is expected within few years. This last observation highlight the need of an immediate response from public health policy makers in order to resolve the problem of infant malnutrition in Ecuador and keep aliened with the 2030 Agenda for Sustainable Development.
Still our work has some limitations that should be considered. First, because of the nature of our study design we were unable to stablish a causal association between malnutrition and delayed gross motor development. Second, despite we adjusted our statistical models by influential confounders including age and mother’s level of education, we were not able to take into account the impact of other important factors such as birth weight. Nevertheless, our models were able to explain a substantial part of the outcome variance and had a good level of classification accuracy. Third, although the exposure was objectively measured following international standards, the measure of achievement of gross motor milestones relayed on the information given by caregivers, probably introducing information bias.