Low Birth Weight (LBW)
Protein Energy Malnutrition (PEM)
Iron Deficiency Anaemia
Iodine Deficiency Disorder (IDD)
Vitamin A Deficiency
Other Micro-Nutrient Deficiencies
Urinary Bladder Stone Disease
Nutrition Related Health Problems
Despite the overall economic thriving conditions and the bounty of food during the 1980s, there are still considerable nutritional problems. However, during the decade, Thailand has reduced the magnitude and severity of the problems, especially protein energy malnutrition (PEM). Current nutrition problems and their trends can be summarized as follows:
There has been a slight improvement of low birth weight prevalence in Thailand during 1980s. In 1989 and 1991 the overall prevalence of LBW (under 2,500 gm.) were 9.5% and 9.0% respectively for the whole country. In 1982, the regional prevalences were 8.2%, 9.3%, 10.4%, and 12.8% in the Southern, the Central, the North-eastern, and the Northern regions respectively while in 1991 the figures were 9.5%, 9.2%, 9.4%, and 10.2% respectively as shown in Table 32. For the Bangkok area, the prevalence of LBW in 4 major hospitals in 1982 ranged from 4.6% in an elite teaching hospital to 9.2% in a general hospital and showed relatively no changes over time (4.6% in 198836 and 9.7% in 199137 respectively). Among the hypotheses why the North has the highest LBW prevalence is the high percentage of minority hill-tribes, the fact that it is an IDD endemic area and the high smoker prevalence among women.
36. Unpublished data from the Department of Obstetric and Gynecology, Ramathibodi Hospital. Bangkok, Thailand 1988.37. Department of Health. Report of the incidence of low birth weight in the Bangkok metropolitan area, 1991. Bangkok Metropolitan Administration, Thailand 1991.
The prevalence of protein energy malnutrition (PEM) by weight-for-age in children under five who reflect macro-nutrients deficiency was 53% between 1979-1982. Since the growth monitoring activities were institutionalized by the Division of Nutrition, MOPH at the beginning of the fourth NESDP in 1981, Thailand has achieved a dramatic reduction in PEM according to the National Growth Monitoring Quarterly Report by the MOPH with a coverage of more than 2.6 million pre-school children. Using the Thai growth standard the combined mild, moderate and severe malnutrition by weight-for-age as shown in Table 33 declined consistently from 50.8% in 1982 to 18.6% in 1990 (for moderate and severe combined from 15.1% to 0.8% in the same period). The north-east has consistently been the worse-off region. The combined malnutrition rate in 1990 in this region was 24.6% compared to less than 10% in the east and central region (Table 34).
A recent study in 24 north-east villages in 1990 has indicated that PEM in this worse-off region also has seasonal variations38. The combined malnutrition in the dry season (March-May) was higher (48.3%) than the same group of pre-school children (37.5%) in the cold-dry and post-harvest seasons. This might reflect the seasonal food shortage in this region. Using the NCHS standard, the percentage of the children who fell below -2 SD cut-off points in the hot-dry season were 34.7%, 28.1% and 9.9% by weight-for-age, height-for-age and weight-for-height respectively (Table 35). This can be considered as the worst case scenario, since the north-east is the poorest region and food in the hot-dry season is scarce. For comparison, the 1987 Demographic Health Survey showed the prevalence of pre-school children falling below -2 SD. of the NCHS Standard by W/A, H/A and W/H at 25.8%, 5.7% and 22.4% respectively. The figures indicate that children in the north-east are more chronically malnourished (H/A) than Thai children (overall) in 1987. The improved W/H indicator observed in 1990 compared with that in 1987 should be viewed with caution since they already suffer stunting.
38. Kachondham, Y. et al. Report on IDRC's Integrated Nutrition Project in North-east Thailand, Phase 1. Institute of Nutrition, Mahidol University, 1992.It is quite difficult to make any international comparison since the nationwide growth monitoring activities collect only weight-for-age data using the Thai Standard instead of the NCHS Standard. However, using the database of a recent study in the north-east to create a set of adjusted factors, the PEM prevalence using W/A indicators and the -2 SD NCHS Standard cut-off point might be 33.9%-36.4% in 1982 and 12.4%-13.3% in 1990 (Table 36). Furthermore, another interesting point regarding the nationwide growth monitoring report is that the coverage percentage might be overestimated since according to the population age structure, children under 6 should be approximately 5 to 6 million during the period. To say that the growth monitoring had 89% coverage (in Table 33) when only 2.6 million children participated is improbable even subtracting all children in the urban areas who were usually not counted in the nationwide growth monitoring activities. Thus, the achievement might be overestimated since those who were left out were mostly temporary migrants or the economically deprived. Nevertheless, there is no doubt that tremendous improvements in the nutritional status among Thai children did happen in the 1980s.
Iron deficiency anaemia was first described as a public health problem in a 1962 nutrition survey by a joint Thai-US group of scientists of the Interdepartmental Committee on Nutrition for National Defence39. Studies in the south from 1980-1988 indicated prevalence rates as high as 30-43.3%40 41 42. Iron-deficiency anaemia using hematocrit classified by WHO criteria among pregnant women in 1986 were widespread, at its highest in the Eastern region (35.9%) and lowest in the North (20.4%)43. For children aged 0-5, 29.2% of them were anemic in the 1988 national nutrition survey, reduced to 15% in 1991. The prevalence of anaemia in school-age children and pregnant women from the hospital-based data has been reduced from 27.3% and 27.3% in 1988 to 18.6% and 18.8% in 1990 respectively (Table 37). People in the South seem to have the highest prevalence of anaemia. It may be the climatic, occupational and life style conditions (i.e. tropical forest and not wearing shoes while working in rubber plantations) that may be conducive to higher hookworm infestation among people in the South. Since Thalassemia and Thalassemia trait are inherent problems among the Thai in the North and the North-east, iron deficiency anaemia prevalence may be overestimated due to the inclusion of those who are thalassemic.
39. ICNND (U.S. Interdepartmental Committee on Nutrition for National Defense). Kingdom of Thailand Nutrition Survey Oct-Dec, 1960. Washington DC: Department of Defense, 1962.Most pregnant women currently have access to antenatal care and usually get iron supplementation in the first visit. Iron supplementation for at least 3 months is recommended and compliance is doubtful since only half of pregnant women have 4 antenatal visits or more (Table 32). Poor compliance issues include (i) lack of good communication to warn pregnant women in advance against black stools and dyspepsia that may follow iron tablet ingestion; and (ii) "Nurturing tablets", a collective term often used by health providers for vitamin and iron tablets, may be wrongly perceived by pregnant women for fear of having a big foetus and painful labour. To improve iron supplementation compliance these issues certainly have to be addressed.40. Nutcharas U, et al. Anemia in Muslim villages of Thailand. Health and Environment 1987; May-Aug: 5-11.
41. Surapruek P, et al. Anemia in South Thailand: A Preliminary Study, Songkla, Thailand. Songkla Med J 1980; 2(1):38-50.
42. Tintara H, Kor-anantakul O, and Pornpatkul M. Causes of Anemia in Pregnant Women in Hat Yai, Songkla. Songkla Med J 1988; 6(3):268-76.
43. Thaineur V. Direction and Nutritional Activities in the 6th National Economic and Social Development Plan. Nutrition Division, Ministry of Public Health, 1987.
The Northern region and some provinces in the north-east are categorized as goitre endemic. A national iodine deficiency disorders (IDD) control programme has been underway since 1989. The prevalence of IDD at present has been determined on the basis of physical examination of children in rural primary schools where teachers have been trained to screen for goitre. The prevalence of goitre in these 15 provinces declined from 19% in 1989 to 16.8% in 1990 and the goitre rates in each affected province are shown in Table 38. Moreover, the Nutrition Division Report in 1991 indicated that prevalence of goitre in school children might be as high as 37.9% in 10 upper north-east provinces and 26.5% in 11 central provinces. Since interrater agreement on goitre is not always reliable, these data are subject to verification by better methods i.e. urinary iodine, cord blood Thyroid Stimulating Hormone (TSH) and other tests. According to the Nutrition Division, these techniques will be used in random samples to verify and improve the quality of screen data reported by school teachers.
Current control measures include the distribution of iodized salt, iodate concentrated stock solution drops in community wells, drinking water tanks at school and at home in villages where goitre rates exceed 5%. Iodized oil capsules (200 mg) are also provided for women of child-bearing age and pregnant women in those villages where goitre rates are greater than 20% or those villages that have cretins of less than 5 years of age.
The existence of vitamin A deficiency as a public health problem is not clear. Information on vitamin A deficiency's magnitude and geographical distribution is obtainable through accumulated small scale surveys and research studies. Nonetheless, studies have shown the decline of vitamin A deficiency prevalence over the last two decades as follows. A 1977 survey in Ubon Ratchathani province in the North-east demonstrated that 17% of 146 preschool children showed deficient serum retinol levels (less than 10 mcg/dl) and as much as 70% of the children studied had marginal serum vitamin A (10-20 mcg/dl). Results in school children were 22% for deficient and 51% for marginal levels44. In 1987 the prevalence of deficiency levels and marginal levels in school children in the same areas reduced to 1.3% and 16.8% respectively45. In the 1990 survey in the North and the North-east, marginal serum retinol between 10-20 mcg/dl were found in 14% and 7% of the pre-school children in the dry and the rainy seasons, respectively, due largely to an increase in vitamin A-rich foods during the latter period46. Thus, it may be concluded that, although xerophthalmia and deficient serum levels existed during the 1960's47 to mid 1970's, the problem declined to marginal levels, rather than severe ones, during the mid-1980's. Nevertheless, sporadic cases of clinical manifestations and deficient serum retinol levels in pre-school children can still be found in some specific areas in rural north and north-eastern Thailand48.
44. Dhanamitta S, Stoecker B and Valyasevi A. Community Approaches to the Prevention of Vitamin A Deficiency. Paper presented at the IVACG Meeting, Jarkarta, Indonesia, 11-13 October 1980.45. Dhanamitta S, Viriyapanich T and Kachonpadunkitti Y. Vitamin A deficiency in Thailand. In: Proceedings of the Fifth Asian Congress of Nutrition. Yasumoto K et al., eds. Center for Academic Publications. Tokyo, 1987.
46. Nutrition Division and the Institute of Nutrition at Mahidol University. Report on Prevalence of Inadequate Vitamin A Nutriture in Pre-school Children of the North and Northeast Thailand. Department of Health, Ministry of Public Health. Bangkok, 1991.
47. Interdepartmental Committee on Nutrition for National Defence (ICNND). The Kingdom of Thailand Nutrition Survey (October-December 1960). Department of Defence. Washington, D.C. 1962.
48. Bloem M, et al. The Prevalence Study of Vitamin A Deficiency and Xerophthalmia in Northeastern Thailand. Am J Epidemiol 1989; 129:1095-1103.
Other micro-nutrient deficiencies are also quite common and prevail in certain vulnerable groups. Despite the general impression that riboflavin deficiency was common among rural dwellers, there is little knowledge about its epidemiological nature. A study was conducted in 32 villages in two north-eastern provinces (Khon Kaen and Nakorn Rajsima), covering 430 under-fives49. The overall prevalence of riboflavin deficiency, measured by erythrocyte glutathione oxidoreductase activity, was 16%. The highest prevalence was in the first year age group (21%). A similar survey was done in Bangkok children from a well baby clinic, and found a prevalence of only 2%.
49. Vudhivai N, et al. Riboflavin status in preschool children in northeast Thailand: A community survey. J Med Assoc Thai 1986; 69:543-8.Since the problem is not fatal, nor does it cause serious injuries, it has received very little attention. Angular stomatitis was very obvious during certain times of the year. At least half of school children in the north-east might have had various stages of angular stomatitis during the peak period. Thereafter, it is cured by itself without treatment.
Urinary bladder stone disease has been listed in the past as one of the major nutritional problems in Thailand. Its striking characteristics were the high prevalence in young children and the stone composition. Phosphorus deficiency was identified as the causal factor, and was related to infant feeding practices in the north and north-east where the prevalence was high50. In the studied population in 1963, 3.8% of them, at one time in their life, may have had active bladder stone disease51. There have been no reports on the present trend. The only evidence was the decline in the number of patients admitted for urinary stone operation. A follow-up from hospital records in Chiang-mai (north) between 1962 and 1984 showed a marked decline in the proportion of children under 10 years old admitted for stone operations (64% of lower urinary tract and bladder stone patients in 1962, 26% in 1974 and 3.8% in 1984). There have been no epidemiological studies to support the trend.
50. Van Reen R, Valyasevi A, Dhanamitta S. Studies of Bladder Stone Disease in Thailand, VIII. Sulfate Excretion by Newborn and Infants: Possible Relationship of Protein Malnutrition to Bladder Stone Disease. Am J Clin Nutr 1967; 20:1378-1386.51. Halstead SB, Valyasevi A. Studies of Bladder Stone Disease in Thailand, III. Epidemiologic Studies in Ubol Province. Am J Clin Nutr 1967; 20:1329-1339.
The burden of specific nutritional deficiency diseases co-exists with many complex nutritional problems, which put a tremendous strain on the current research organization and its resources. Due to uneven prosperity in society, inadequate consumer protection and unmitigated environmental dangers, Thailand is now enduring a new chapter of nutrition-related health threats in rapid transition, with malnutrition and other deficiency diseases co-existing with the diseases of affluence.
The Nutrition Division reported that the prevalence of overnutrition (W/H > 120% standard weight) in Bangkok school children aged 6-12 (N = 267) was 22.3% in male and 16.45 in female students. A nutrition survey of 3,494 officers of the Electricity Generating Authority of Thailand in the mid 1980s indicated that 23.3% of male and 18.8% of female officers were obese52. Heart disease, the number one killer (30 deat per 100,000 persons per year) in recent mortality statistics since 1980, and hypertension are known to be associated with overnutrition especially among the well-to-do class (see also in section 3.2). The dreadful Sudden Nocturnal Death Syndrome, a disease causing untimely deaths among workers working outside Thailand is believed to have nutritional etiology due to thiamine (B1) deficiency and low potassium intake in the diet. Certain kinds of cancer are related to over-consumption of fat and contamination with toxic substances in the food chain as the price of uncontrolled environmental hazards and rapid industrial development.
52. Pakpeankitvatana R, Tanphaichitr V, Lochaya S, et al. Clinical and epidemiological studies on hyperlipidemia in urban Thais. In: Yasumoto K, et al, eds. Proceedings of the Fifth Asian Congress of Nutrition. Center for Academic Publications, Tokyo 1988:430-3.
