The effect of globalisation on toddler nutrition

The challenge lies in the fact that a toddler’s nutritional requirements are increased but at the same time, their stomach capacity is small¹. Therefore a regular daily meal pattern of three small meals and two or three snacks is essential to meet these elevated requirements, which when calculated per kilogram body weight, is higher than those of adults and older children.

A healthy toddler menu should include a combination of foods from all five food groups, in order to meet all of their nutrient requirements:

1. Each meal must include some bread, cereals or potatoes.
2. Five small servings of fruit and vegetables are encouraged.
3. Three servings of milk, cheese or yogurt will provide enough protein and calcium, without affecting their appetite.
4. Meat, fish, eggs, nuts and pulses provide the richest sources of iron in the diet.
5. Foods high in energy, fat and sugar should be offered sparingly alongside the other groups for energy and to supply the vitamins A, D and E.

A multicultural nation
The UK is a multicultural nation of 60.6 million people from different racial, religious and cultural backgrounds. Today, approximately 4.6 million people, or 7.9% of the population, are from a minority ethnic group according to the 2001 census. While the majority ethnic group is classified as “White British”, the proportion of individuals classified as “White” decreased from 93% in 2001 to 90% in 2007. The largest minority groups are Asian or Asian British (3.6% of the UK population) and then Black or Black British (Caribbean and African) (1.8%)^2,3. The UK´s diversity is a great asset but it also brings challenges⁴.

It is now acknowledged that people from the minority group population are disadvantaged in terms of health⁵. Health problems are often compounded by factors such as poverty, unemployment, poor housing, communication difficulties and social isolation. Many of these problems have nutritional implications. There is enormous diversity in culture, traditions and food habits between and within different ethnic groups, and even within a single family. About half of those from minority ethnic groups in the UK were born in this country, a proportion which will increase steadily with time, and as a result, Western influences on diet have affected traditional eating patterns to a considerable extent. Some people consume a diet that is no different to that of their indigenous peers; others, particularly those who have recently immigrated, retain their traditional eating practices. Most of the traditional dietary practices are compatible with guidelines for healthy eating. Dietary imbalance tends to occur when traditional food habits are eroded or supplanted by some of the less desirable aspects of the European diet⁶.

Nutrient intakes
The 1995 National Diet and Nutrition Survey (NDNS) showed that the majority of children in the UK had adequate intakes of most vitamins except Vitamins A, C and D⁷. The survey reported that calcium intakes were adequate. The contribution of milk and milk products to calcium intake was highest in the youngest children in the 1.5- 4.5 years age band and decreased with age. However, intakes of iron, zinc and copper were found to be low⁸.

A common deficiency
Iron deficiency is common in toddlers, particularly in socially disadvantaged groups and in the immigrant population^7,9. Between the ages of 1-3 years, the Reference Nutrient Intake (RNI) for iron is 6.9mg/day, reflecting a high requirement during this period of rapid growth and development. The RNI is reduced to 6.1mg/day in those aged 4-6 years¹⁰. Iron deficiency in young children is usually of dietary origin. The early introduction of cows’ milk as a main drink before 12 months of age and over-dependence on milk where it replaces iron-rich or iron-enhancing foods are two of the main causes of iron deficiency^{11, 8}.

The prevalence of breastfeeding is higher among Asian mothers, and weaning is more likely to be delayed. By the age of 9 months, cows’ milk is more likely to be used as a main drink than formula, keeping in mind that the former contains insufficient amounts of micronutrients compared to the latter.

In the case of Chinese traditions, infant formula milk is seen as very “hot”, so a Chinese mother may want to give her bottlefed baby “cooling” drinks such as boiled water or barley water. In addition,the perceived lack of manufactured halal meat-based weaning foods may be partly responsible for the low iron intakes commonly found in infants of Asian origin ¹². As a result, the risk of anaemia in Asian children is much higher. Lawson et al (1998)⁹ found that 29% of Pakistani, 25% of Bangladeshi, and 20% of Indian children had haemoglobin levels below 11.0g/dl compared with about 12% of 2 year old children in the general UK population⁷.

Low vitamin D status
Another common deficiency seen in toddlers, and especially those of ethnic minority origin, is of Vitamin D. Inadequate dietary vitamin D and/or calcium intake, darkly pigmented skin, inadequate exposure to sunlight due to excessive clothing, remaining indoors for seasonal, cultural or religious reasons and air pollution are the main causes for this deficiency¹³.

The typical African diet is rich in grains that contain inhibitors of calcium absorption such as phytates, oxalate, tannates, and phosphates. On the other hand, in Asians and other cultures, increased skin pigmentation, diminished exposure to sunlight in more northern climates and a reduced dietary intake of vitamin D may be contributory factors to the high prevalence of vitamin D deficiency.

Additionally, breastfed infants with limited sunlight exposure are at higher risk of vitamin D deficiency than formula fed infants because breast milk contains insufficient amounts of Vitamin D to prevent rickets. Darkly pigmented skin requires longer sunlight exposure than light skin to maximise vitamin D formation, therefore dark-skinned mothers are at increased risk of being vitamin D deficient. Their infants are more likely to have low vitamin D stores at birth, receive less vitamin D in breast milk and produce less vitamin D themselves from sunlight. As a consequence, as the number of infants who breastfeed increases, so does the number of infants at risk of vitamin D deficiency. The Reference Nutrient Intake (RNI) is the amount of each nutrient that is adequate to prevent deficiencies in 97.5% of the UK population. Although the RNI for vitamin D for toddlers has been set at 7 micrograms/day, the dose, schedule and duration of vitamin D supplementation as well as the target population remain controversial due to the lack of well designed clinical studies on these matters¹⁰.

Implications for health
Whilst growth velocity is greater during infancy than in toddlerhood, toddlers do experience rapid growth and development. During periods of rapid growth and development, a child may be particularly vulnerable to inappropriate dietary patterns and nutrition¹⁴. An insufficient or excess supply of energy and/or other nutrients during critical windows of growth and development may program a child to develop health conditions such as overweight, diabetes, and hypertension in childhood or later in life¹⁵. In addition, some micronutrient deficiencies during early life result in irreversible deficits in mental and motor development. New research on the importance of specific nutrients in promoting growth and development of infants and long-term health of adults is prompting scientists to consider the potential importance of these nutrients for toddlers as well.

In view of the above, health professionals are obliged to provide parents with all the information, support, and tools necessary to avoid malnutrition in toddlers. Families from ethnic minorities will tend to require more assistance, as they tend to be more vulnerable when in foreign countries. The best way to approach these issues is through promotion, prevention and early intervention for health, in order to avoid any consequences that may affect a child’s growth and development in the long run. For more information and advice about food, health visitors and parents may refer to the Food Standards Agency´s websites: eatwell.gov.uk; food.gov.uk¹⁶.

References
1. Carruth BR et al. The Phenomenon of “Picky Eater”: A Behavioural Marker in Eating Patterns of Toddlers. Journal of the American College of Nutrition 1998; 17(2): 180-186.
2. Office for National Statistics (ONS). Social focus: Ethnicity. London: ONS. 2004. (Available at www.statictics.gov.uk).
3. Office for National Statistics (ONS). Table EE4, Population Estimates by Ethnic Group Rel 8.0, Office for National Statistics. 2011.
4. Turnbull B et al. Toddler Diets in the UK: deficiencies and imbalances. 1. Risk of Micronutrient Deficiencies. Journal of Family Health Care 2007; 17(5): 167-70.
5. State University.com. Poverty and Education- Overview, Children and Adolescents- Poor Income, School and Family [Online]. 2011. Available at:http://education.stateuniversity.com/pages/2330/Poverty-Education.html">Poverty and Education - OVERVIEW, CHILDREN AND ADOLESCENTS [Accessed October 2011].
6. Lanigan J et al. Toddler Diets in the UK: deficiencies and imbalances. 2. Relationship of Toddler Diet to Later Health. Journal of Family Health Care 2007; 17(6): 197-200.
7. Gregory JR et al. National Diet and Nutrition Survey: Children Aged 1 ½ to 4 ½ Years. Volume 1. Report of the Diet and Nutrition Survey. London: HMSO, 1995.
8. Thane CW et al. Risk factors for poor iron status in British toddlers: further analysis of data from the National Diet and Nutrition Survey (NDNS) of children aged 1.5-4.5 years. Public Health Nutrition 2000; 3: 433-440.
9. Lawson MS et al. Iron status of Asian children aged 2 years living in England. Archives of Disease in Childhood 1998; 78: 420-426.
10. Department of Health (DH). Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report on Health and Social Subjects 41. London: HMSO, 1991.
11. Cowin I et al. ALSPAC Study Group. Association between composition of the diet and haemoglobin and ferritin levels in 18 month old children. European Journal of Clinical Nutrition 2001; 55: 278-286.
12. Williams S, Sahota P. An enquiry into the attitudes of Muslim Asian mothers regarding infant feeding practices and dental health. Journal of Human Nutrition and Dietetics 1990; 3: 393-402.
13. Calikoglu AS, Davenport ML. Prophylactic Vitamin D Supplementation. In: Hochberg Z (ed). Vitamin D and Rickets. Endocrine Development. Basel, Karger, 2003. Vol 6, 233-258.
14. Woody, D. (2003b) Infancy and toddlerhood. In Hutchinson E (ed.) Dimensions of Human Behaviour: The Changing Life Course, 2^nd edn. Thousand Oaks, CA: Sage, pp. 111-155.
15. Caprio S et al. Influence of Race, Ethnicity, and Culture on Childhood Obesity: Implications for Prevention and Treatment. A Consensus Statement of Shaping America´s Health and the Obesity Society. Diabetes Care 2008; 31(11): 2211-2221.
16. Food Standards Agency. Feeding your Toddler. 2002.