The Relationship between Energy, Nutrition, and Dietary Fiber

Intake with the Nutritional Status of Down Syndrome Children

Lusi Anindia Rahmawati

, Sri Anna Marliyati

and Ikeu Ekayanti

Department of Nutrition, Faculty of Science and Technology, Universitas Al-Azhar, Indonesia

Department of Community Nutrition, Faculty of Human Ecology, IPB University, Indonesia

Keywords: Down Syndrome, Intake, Nutritional Status.

Abstract: Down syndrome is one of the disability conditions that can reduce productivity especially if coming with

nutritional problems. Overweight is a nutritional problem that often occurs on Down Syndrome children.

This research was aimed to understand the relationship between energy, nutrition, and fiber intake and the

nutritional status of Down syndrome children. The design of this study was a cross-sectional study. As

many as 50 samples were selected using purposive sampling from five extraordinary schools in Magetan

East Java. Structured interviews and a 2x24 hour recall questionnaire were conducted with mothers of

Down Syndrome children. According to the z-score of BMI for age, 40.0% of children in this study were

overweight and obese, 52.0% was normal, and 8.0% was found to have thin and severely thin nutritional

status. Based on the bivariate analysis, energy intake, carbohydrate intake, and fiber intake were not

significantly associated with the nutritional status of children with Down syndrome (p>0.05). Protein intake

(p=0.018) and fat intake (p=0.027) were significantly associated with the nutritional status of children with

Down syndrome.

1 INTRODUCTION

Disability is one of the conditions that may reduce

productivity. Down syndrome is one of the disability

due to a genetic disorder that occurs during fetal

growth (on chromosome 21/trisomy 21). The

symptoms might greatly vary, from mild to severe

that was mental retardation with the IQ level of less

than 70, facial profile (Mongoloid), and typical palm

line (simian crease) (Ministry of Health, 2013).

The global number of patients with Down

syndrome indicated an increased trend of 30% in

1979-2003 (Shin et al., 2009). According to the data

of Basic Health Research, the percentage of children

with Down syndrome increased from 0.12 in 2010

to0.13 in 2013 (Ministry of Health, 2013).

Furthermore, data of the National Socio-economic

Survey 2003 issued by the Central Bureau of

Statistics 2003 indicated that East Java had the most

patients with mental retardation in Indonesia with 17

550 patients with Down syndrome (Central Bureau

of Statistics, 2003). The high prevalence requires

special attention to improve their life quality.

Nutritional status is one of the factors affecting

an individual life quality. The study that was

conducted by Nursilmi et al. (2017) showed that

there is a positive correlation between nutritional

status and the life quality of physical health and the

environment. The better the nutritional status, the

better the individual life quality. Overweight is a

nutritional problem that often occurs in children with

Down syndrome. The study that was held by

Oosterom et al. (2012) showed that children with

Down syndrome are more potential for suffering

from overweight and obesity than other children. In

addition to that, based on Marin and Graupera

(2011), most children with Down syndrome have

both overweight and obese nutritional status.

Overnutrition on children with Down syndrome

shall be prevented as it may deteriorate their health.

Besides, overweight and obesity suffered by children

with Down syndrome will restrict their opportunities

to participate in social, recreational, and sports

activities significantly contributing to their physical

and emotional development (Marin and Graupera,

2011).

Factors directly influencing nutritional status are

food intake and infection (Supariasa et al., 2002).

Yulni (2013) in her study on elementary school

children found a correlation between energy intake

346

Rahmawati, L., Marliyati, S. and Ekayanti, I.

The Relationship between Energy, Nutrition, and Dietary Fiber Intake with the Nutritional Status of Down Syndrome Children.

DOI: 10.5220/0009768703460350

In Proceedings of the 1st International Conference on Health (ICOH 2019), pages 346-350

ISBN: 978-989-758-454-1

and carbohydrate and nutritional status. Based on the

studies above, we are interested in the correlation

between nutrient intake and nutritional status on

children with Down syndrome. The research is

conducted to examine the correlation between

energy, nutrition, and dietary fiber intake with the

nutritional status of Down syndrome children.

2 MATERIALS AND METHODS

2.1 Study Design and Subjects

The research used a cross-sectional study design and

conducted in April-June 2015. The research subjects

were 50 students with Down syndrome from five

extraordinary schools in Magetan. They were

selected using purposive sampling and based on

inclusion criteria i.e. 1) aged 6-8 years old, 2) having

no chronic disease, 3) currently living with their

biological mothers, and 4) with mothers willing to

participate in the research.

2.2 Data Collection and Analysis

Data collected comprised of characteristics,

nutritional status, and nutrient intake of subjects.

Data collection of the subject characteristics were

conducted through structural interviews using

questionnaires with mothers of Down Syndrome

children. Nutritional status data were gathered using

an anthropometric measurement of body weight and

body height. Bodyweight was measured using a

body scale; while body height was measured using a

microtome. Nutrient intake data were collected

through interviews with the mothers of Down

Syndrome children using 2×24 recall questionnaires.

Data collected were analyzed using SPSS for

Windows verse 16. Univariate analysis was

conducted to investigate the distribution of each

variable. To observe the correlation between energy,

nutrition, and fiber intake and nutritional status of

the subjects, we conducted Spearman correlation

test. The odds ratio was calculated based on the 95%

confidence interval (CI).

3 RESULTS

3.1 Characteristics of Subjects

From 50 subjects, 33 (66.0%) were males and 17

(34.0%) were females. Distribution of the subject

age was 29 (58.05) subjects aged ≤12 years old, 21

(42.0%) others were aged >12 years old.

Table 1: Distribution of the characteristics of subjects.

Characteristics n %

Sex

Male 33 66.0

Female 17 34.0

Total 50 100.0

Age

≤ 12 years old 29 58.0

> 12 years old 21 42.0

Total 50 100.0

3.2 Nutritional Status of Subjects

Nutritional status was categorized based on Body

Mass Index in accordance with age (BMI for Age)

for children aged 5-18 years old (Ministry of Health,

2011). More than half of the subjects had a normal

nutritional status (n = 26). 11 subjects (22.0%) had

an overweight nutritional status, and 9 (19.0%)

subjects had an obese nutritional status. Of the total

subjects, 2 (4.0%) subjects had a severely thin

nutritional status, and 2 (4.0%) other subjects had a

thin nutritional status.

Table 2: Distribution of the nutritional status of subjects

based on BMI for Age.

Nutritional Status n

Severel

thin 2 4.0

Thin 2 4.0

Normal 26 52.0

Overwei

ht 11 22.0

Obese 9 18.0

Total 50 100.0

3.3 Energy, Nutrition, and Dietary

Fiber Intake

Energy, nutrition, and dietary fiber intake of subjects

were categorized based on the adequacy level. The

mean of energy intake of subjects was 1,900 kcal.

Most subjects (42.0%) had the energy adequacy

level categorized as excessive (≥ 120% RDA),

34.0% had the energy adequacy level categorized as

deficit (< 90% RDA), and 24.0% had the energy

adequacy level categorized as normal (90-119%

RDA).

Protein adequacy level was normal when in the

range of 90.0-119.0% of Recommended Dietary

Allowance (Gibson, 2005). The mean of protein

intake of the research subjects was 54 grams. Of 50

The Relationship between Energy, Nutrition, and Dietary Fiber Intake with the Nutritional Status of Down Syndrome Children

347

subjects, 10 (20%) had a protein adequacy level

categorized as normal; while 40 others had a protein

adequacy level categorized as deficit and excessive

(20 subjects for each).

The recommended total fat intake for children

aged 4-18 years old was 25.0-35.0% of calories for

children (Hardinsyah et al., 2014). Of 50 subjects, 8

(16%) had a fat adequacy level categorized as

normal. 42 others had a fat adequacy level

categorized as deficit and excessive (22 and 20

subjects for each, respectively). The mean fat intake

of the subjects was 60.7 grams.

The recommended carbohydrate intake for

children aged 4-18 years old was 45.0-65.0% of

calories for children (Hardinsyah et al., 2014). The

mean carbohydrate intake of the subjects was 414.9

gram. Most of the subjects (64.0%) had an excessive

carbohydrate adequacy level. 28.0% of subjects had

a carbohydrate adequacy level categorized as

normal; while 8.0% others had a carbohydrate

adequacy level categorized as a deficit.

The recommended amount of fiber intake to

prevent obesity and non-infectious diseases was 25

g/day (Perkeni, 2011). All research subjects (100.0%)

had fiber intake categorized as inadequate. The mean

of fiber intake of the subjects was 6.0 g/day.

Table 3: Distribution of subjects based on the level of

energy, nutrition, and dietary fiber adequacy.

Variable n

Ener

Deficit

(

< 90% RDA

)

17 34.0

ormal

(

90-119% RDA

)

12 24.0

Excessive

(

≥

120% RDA

)

21 42.0

The mean of ener

intake ± sd

(

kcal

)

1900 ± 572

Protein

Deficit

(

< 90% RDA

)

20 40.0

ormal

(

90-119% RDA

)

10 20.0

Excessive

(

≥

120% RDA

)

20 40.0

The mean of

rotein intake ± sd

ram

)

54 ± 20.3

Fat

Deficit

(

< 25% of calories

)

22 44.0

ormal

(

–

35% of calories

)

8 16.0

Excessive

(

> 35% of calories

)

20 40.0

The mean of fat intake ± sd

ram

)

60.7 ± 28.9

Carboh

drate

Deficit

(

< 45% of calories

)

48.0

ormal

(

–

65% of calories

)

14 28.0

Excessive

(

> 65% of calories

)

The mean of carbohydrate intake ± sd

ram

)

414.9 ± 243.7

Fibe

Inade

uate

(

< 25

50 100.

Ade

uate

(

≥

00.0

The mean of fiber intake ± sd

ram

)

6.0 ± 3.5

3.4 Correlation between Energy,

Nutrition, and Dietary Fiber Intake

with the Nutritional Status of

Subjects

Referring to Spearman correlation analysis, the

protein and fat intake variables significantly related

to overweight and obese nutritional status on the

subjects (p < 0.05). Subjects with excessive protein

intake (≥ 120% RDA) were potential for obesity 4.1

higher than subjects with adequate protein intake (<

120% RDA). Similarly, subjects with excessive fat

intake (≥ 25% of calories) were potential for obesity

3.9 higher than subjects with adequate protein

intake (< 25% of calories). However, energy,

carbohydrate, and dietary fiber intake did not

significantly relate to the nutritional status of the

research subjects.

Table 4: Correlation between energy, nutrition, and dietary

fiber intake with the nutritional status of subjects.

Variable

Nutritional Status

Overweight/

obese

(n=20)

Normal/

thin

(n=30)

Energy

Excessive 11 52.4 10 47.6 2.4 0.128

Adequate 9 31.0 20 69.0 CI : 0.76-

Protein

Excessive 12 60.0 8 40.0 4.1 0.018*

Adequate 8 26.7 22 73.3 CI: 1.24-

Fat

Excessive 15 53.6 13 46.4 3.9 0.027*

Adequate 5 22.7 17 77.3 CI: 1.13-

Carbohydrate

Excessive 14 43.7 18 56.3 1.6 0.470

Adequate 6 33.3 12 66.7 CI : 0.47-

Fiber

Excessive 9 31.0 20 69.0 0.4 0.128

Adequate 11 52.4 10 47.6 CI : 0.13-

4 DISCUSSION

Although more than half of subjects evidently had a

normal nutritional status, subjects with overweight

and obese nutritional status also came in a high

number. It was in accordance with other studies on

Down syndrome (Koniuszy and Kunowski, 2013;

Marin and Graupera, 2011). According to National

Food Service Management Institute (2006),

overweight was one of the nutritional problems

ICOH 2019 - 1st International Conference on Health

348

majorly suffered by school-age children with Down

syndrome. The nutritional problem should be

prevented to improve their health condition.

In this study energy, nutrition, and dietary fiber

intake of children with Down syndrome indicated an

imbalanced result. Of the total subjects, few had the

recommended energy, protein, fat, and carbohydrate

intake. Even no subject had met the recommended

fiber intake.

Children with Down syndrome tended to

excessively consume food. When interviewed,

several parents complained about their children’s

non-stop eating habits before all of the food was

eaten (especially snack eating). It triggered

excessive energy, protein, and carbohydrate intake

in most children with Down syndrome. It was in line

with Samour and King (2012) study that children

with Down syndrome tended to have higher food

intake than Dietary Reference Intake (DRI).

Furthermore, another study also indicated that

carbohydrate intake of children with Down

syndrome was considered high (Grammatikopoulou

et al., 2008).

All subjects had fiber intake categorized as

inadequate. Various studies on children with Down

syndrome gave a similar result. Almost all children

with Down syndrome had inadequate fiber intake

(Marin and Graupera, 2011; Koniuszy and

Kunowski, 2013; Samarkandy et al., 2012).

Achieving the recommended fiber consumption was

difficult for children with Down syndrome. A study

that was held by Mahan and Stump (2008) showed

that it was due to swallowing and chewing ability

delays in their preschool age. The delays

consequently restricted parents to give various types

of food, especially vegetables.

Disproportional energy, nutrient, and fiber intake

in most subjects were probably due to imbalanced

daily meals. It was supported by the previous study

concluding that daily meals of children with Down

syndrome were imbalanced in terms of energy and

nutrition (Koniuszy and Kunowski, 2013).

Food intake was one of the factors directly

affecting an individual nutritional status. We found

that protein and fat intake significantly correlated

with nutritional status of children with Down

syndrome (p > 0.05). In this study, the odds of being

overweight and obesity in Down syndrome children

with excessive protein intake was 4.1 (95% CI:1.24-

13.78). It suited the study of Del-Mar et al. (2015).

Another study also confirmed that total protein and

high animal protein intake could improve body

weight and IMT (Rolland-Cachera et al., 2004;

Hermanussen, 2008). Some other studies correlated

animal protein intake with obese nutritional status

(Lin et al., 2015; Wang and Beydoun, 2009).

According to the studies, animal protein intake,

especially meat and processed products triggered

high fat intake, saturated fat, and total calorie and

reduced vegetable consumption (Nicklas et al.,

1995).

Several studies indicated a significant correlation

between fat intake and nutritional status (Saker et

al., 2011; Mc Gloin et al., 2002). We figured out that

the odds of being overweight and obese in Down

syndrome children with excessive fat intake was 3.9

(95% CI:1.13-13.60). Bray et al. (2004) declared

that high fat intake might indirectly increase

overweight and obesity risks by increasing energy

density and thus excessive energy intake.

Even though we could not find the correlation

between energy, carbohydrate, and dietary fiber

intake with nutritional status of Down syndrome

children, most children with Down syndrome tended

to not have the recommended energy, nutrient, and

fiber intake. Therefore, efforts to improve the

condition should be made, optimizing health

condition of Down syndrome children.

5 CONCLUSION

In conclusion, in this study, the percentage of

children with Down syndrome and overweight and

obese nutritional status was 40%. Children with

Down syndrome with excessive protein and fat

intake were more potential for obesity. In general,

most children with Down syndrome tended to not

have the recommended energy, nutrition, and fiber

intake. Therefore, efforts to improve the condition

shall be made, optimizing the health condition of

Down syndrome children.

ACKNOWLEDGMENTS

The publication of this research was funded by

International Seminar Grant LP2M Universitas Al

Azhar Indonesia.

REFERENCES

[Ministry of Health] Ministry of Health of the Republic of

Indonesia, 2011. Decree of the minister of health of

the republic of Indonesia on anthropometric standards

The Relationship between Energy, Nutrition, and Dietary Fiber Intake with the Nutritional Status of Down Syndrome Children

349

to assess the nutritional status of children. Jakarta,

Ministry of Health of the Republic of Indonesia.

[Ministry of Health] Ministry of Healthof the Republic of

Indonesia, 2013. Basic Health Research 2013. Jakarta,

Ministry of Health of the Republic of Indonesia.

[NFSMI] National Food Service Management Institute,

2006. Handbook for Children with Special Food and

Nutrition Needs. Oxford, The University of

Mississippi.

[PERKENI] Perkumpulan Endokrinologi Indonesia, 2011.

Konsensus Pengelolaan dan Pencegahan Diabetes

Mellitus Tipe 2 di Indonesia. Jakarta, Perkeni.

Bray, G.A., Paeratakul, S., Popkin, B.M., 2004. Dietary fat

and obesity: a review of animal, clinical and

epidemiological studies. PhysiolBehav. 83: 549 – 555.

Central Bureau of Statistics, 2003. Result of National

Socio-economic Survey 2003. Jakarta, Central Bureau

of Statistics; 2003.

Del-Mar, B.M., Tur, J.A., Morandi, A., Tommasi, M.,

Tomasselli, F., Maffeis, C., 2015. Protein intake as a

risk factor of overweight/obesity in 8-to-12 years old

children. Medicine (Baltimore). 94(52): e2408.

Grammatikopoulou, M.G., Manai, A., Tsigga, M.,

Fachantidou, A.T., Tsinopoulou, A.G., Zakas, A.,

2008. Nutrient intake and anthropometry in children

and adolescents with Down Syndrome-a preliminary

study. Dev Neurorehab. 11(4): 260 – 267.

Hardinsyah, Riyadi, H., Napitupulu, V., 2014. Kecukupan

energi, protein, lemak dan karbohidrat. In Angka

Kecukupan Gizi yang Dianjurkan bagi Bangsa

Indonesia. Jakarta, Kemenkes.

Hermanussen, M., 2008. Nutritional protein intake is

associated with body mass index in young adolescents.

Georgian Med News. 156(156):84 – 88.

Koniuszy, Z.G., Kunowski, M., 2013. Glycemic Index and

Glycemic Load of diets in children and young people

with Down Syndrome. Acta Sci. Pol.,Technol.

Aliment. 12(2): 181 – 194.

Lin, Y., Mouratidou, T., Vereecken, C., Kersting, M.,

Bolca, S., Moraes, A.C.F., Garcia, M.C., Moreno,

L.A., Gross, M.G., Valtuena, J., et al., 2015. Dietary

animal and plant protein intakes and their association

with obesity and cardio-metabolic indicators

inEuropean adolescents: The HELENA cross-sectional

study. Nutr J. 14(10): 1 – 11.

Mahan, L.K., Stump, S.E., 2008. Krause’s Food and

Nutrition Therapy. 12th ed. Missouri, Saunders

Elsevier.

Marin, A.S., Graupera, J.M.X., 2011. Nutritional status of

intellectual diasbled persons with Down Syndrome.

Nutr Hosp. 26 (5): 1059 – 1066.

McGloin, A.F., Livingstone, M.B., Greene, L.C., Webb,

S.E., Gibson, J.M., Jebb, S.A., Cole, T.J., Coward,

W.A., Wright, A., Prentice, A.M., 2002. Energy and

fat intake in obese and lean children at varying risk of

obesity. Int J ObesRelatMetabDisord. 26(2): 200- 207.

Nicklas, T.A., Farris, R.P., Myers, L., Berenson, G.S.,

1995. Impact of meat consumption on nutritional

quality and cardiovascular risk factors in young adults:

the Bogalusa Heart Study. J Am Diet Assoc. 95:887–

892.

Nursilmi, Kusharto, C.M., Dwiriani, C.M., 2017.

Hubungan status gizi dan kesehatan dengan kualitas

hidupo lansia di dua lokasi berbeda. Jurnal MKMI.

13(4):369-379.

Oosterom, H.B.M.V.G., Dommelen, P.V., Schonbeck, Y.,

Murphy, A.M.O., Wouwe, J.P.V., Buitendijk, S.E..

2012. Prevalence of overweight in Dutch children with

Down Syndrome. Pediatrics. 130 (6): 1520 –1526.

Rolland-Cachera, M.F., Thibault, H., Souberbielle, J.C.,

Soulie, D., Carbonel, P., Deheeger, M., Roinsol, D.,

Longueville, E., Bellisle, F., Serog, P., 2004. Massive

obesity in adolescents: dietary interventions and

behaviours associated with weight regain at 2 y

follow-up. Int J ObesRelatMetabDisord. 28(4): 514–

519.

Saker, M., Merzouk, H., Merzouk, S.A., Ahmed, S.B.,

Narce, M., 2011. Predictive factors of obesity and their

relationships to dietary intake in schoolchildren in

Western Algeria. J Clin Med. 6(2): 90 – 99.

Samarkandy, M.M., Mohamed, B.A., Al-Hamdan, A.A.,

2012. Nutritional assessment and obesity in Down

Syndrome children and their siblings in Saudi Arabia.

Saudi Med J. 33(11): 1216 – 1221.

Samour, P.Q., King, K., 2005. Handbook of Pediatric

Nutrition. 3rd ed. Sudbury, Jones and Bartlett

Publishers.

Shin, M., Besser, L.M., Kucik, J.E., Lu, C., Siffel, C.,

Correa, A., 2009. Prevalence of Down Syndrome

among chidren and adolescents in 10 regions of the

United States. Pediatrics. 124(6):1565-1571.

Supariasa, I.D.N., Bakri, B., Fajar, I., 2001. Penilaian

Status Gizi. Jakarta, EGC.

Wang, Y., Beydoun, M.A., 2009. Meat consumption is

associated with obesity and central obesity among US

adults. Int J Obes (Lond). 33(6): 621- 628.

Yulni, 2013. Hubungan asupan zat gizi makro dengan

status gizi pada anak sekolah dasar di wilayah pesisir

Kota Makassar. Jurnal MKMI. 205-211.

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