Does Height Matter for Girls? A Paediatric Endocrinologist Weighs In

WORDS ASSOCIATE PROFESSOR DR AZRIYANTI ANUAR ZAINI

FEATURED EXPERT
ASSOCIATE PROFESSOR DR AZRIYANTI ANUAR ZAINI
Consultant Paediatrician and Paediatric Endocrinologist
Department of Paediatrics
Faculty of Medicine
University Malaya

Many people are under the impression that it is alright for girls to be short or petite.

While being a few centimetres shorter than the norm may not have much of an effect on a girl or woman, being abnormally short or stunted could have serious psychosocial consequences.

THE RAMMIFICATIONS OF ABNORMAL GROWTH

Mental repercussions. Girls that are too short may face bullying and discrimination, especially among their peers, or they themselves may constantly compare themselves negatively to their normal-height friends.

This can result in psychological distress, low self-esteem, and social isolation.

Discrimination. As they grow up and enter the workforce, this can also translate into discrimination at the workplace, with many studies revealing that shorter people tend to earn less and be viewed as less powerful or influential.

Childbirth issues. Shorter women tend to have smaller pelvises, which may result in difficulties during childbirth. Indeed, research indicates that shorter women tend to have shorter pregnancies, smaller babies and a higher risk of needing a caesarean section.

Practical consequences. Examples include needing a booster seat or car modifications in order to drive and being unable to reach higher items on supermarket shelves or grasp the hanging strap on public transport.

IS YOUR DAUGHTER ABNORMALLY SHORT?

The expected height for a girl or woman is assessed according to their age, population and parents’ heights.

In Malaysia, we use the World Health Organization (WHO) length/height-for-age growth charts to measure the growth of children from birth to the age of 19.

You can get these charts at the WHO website (link opens in a new tab). Note that there are different charts for different sexes and age range, so pick the right one for your child!

A girl whose height is shorter than the average by 10 cm or more on the age-appropriate growth chart should be considered a red flag, and they should be brought to see a doctor as soon as possible.

WHY DO SOME CHILDREN EXPERIENCE STUNTED GROWTH?

Stunting is defined as having a height that was more than two standard deviations from the average height, while risk of stunting was having a height that was between one and two standard deviations from the average.

A nationwide study led by Universiti Malaya, involving over 15,300 children, found that 16.1% of Malaysian children aged 1 to 5 were stunted, while a further 20% were at risk of stunting.

The most common general cause for stunting in Malaysia is malnutrition. This can range from poor nutritional intake due to a low-quality and/or low-quantity diet, to poor behaviour towards nutrition such as slow or picky eating.

Children with a chronic disease, such as congenital heart disease, respiratory illnesses, cancer, or malabsorption disorders, can also suffer from stunting due to factors related to their disease.

In addition, babies born at term and small-for-gestational-age (SGA)–usually less than 2.5kg–can also be abnormally short. Although they may be otherwise healthy, small-for-gestational-age babies that do not catch up in growth by their fourth or fifth birthday are at risk of being stunted.

More specific causes for stunting include hormonal conditions, such as growth hormone deficiency, and genetic conditions such as Turner’s syndrome in girls.

WHAT PARENTS SHOULD PAY ATTENTION TO WHEN IT COMES TO THEIR CHILDREN’S GROWTH

Nutrition. Good nutrition can make a big difference in a child’s growth. It is, in fact, the main driver of linear growth during the first 5 years of life. Even if a child has a hormonal deficiency or genetic condition that causes stunting, ensuring that they receive good nutrition in the early years can go a long way in helping them achieve an optimum height.

Sleep. Many Malaysian children have an unfortunate tendency to go to bed late before having to wake up early in the morning to go to school. Growth hormone tends to be released during the deep, uninterrupted periods of sleep in the middle of the night. Therefore, children who have shorter amounts of such undisturbed sleep may have their growth compromised.

Physical activity. Lastly is our children’s increasingly sedentary lifestyle, which was particularly exacerbated during the movement control order over the last two years. The lack of exercise and tendency to just sit and play with electronic gadgets have a negative effect on a child’s growth. Research has shown that not only is the risk of obesity increased with such a lifestyle, but the child’s growth is also jeopardized.

CAN ABNORMAL GROWTH BE TREATED?

There are definitely ways to treat and manage girls who are abnormally short, but the key influencing factor is the age at which they are diagnosed and when treatment can be commence.

This is because there is only a small window of opportunity to help these girls achieve their maximum potential height.

Despite most parents noticing their daughter’s unusual shortness, many of them only tend to bring their daughter to see the doctor when she fails to have her period by her early teens (primary amenorrhoea).

This is because there is a myth that girls only start their growth spurt after menarche, or their first period. However, the fact is that menarche marks the last stage of puberty. By this time, there is only potential for another 3 to 5cm of growth!

So, while we can still treat such girls, the window of opportunity to help them achieve a more normal height is much more limited.

Ideally, girls with short stature should be referred to a paediatric endocrinologist by the ages of 7 to 10.

This would allow sufficient time for diagnosis, monitoring and treatment.

IN CONCLUSION

It is very important that parents monitor their child’s growth and development.

There are many simple ways parents can keep track of their child’s height at home, including annual measurements—tip: use a cereal box, which has a nice 90⁰ angle, rather than a bendable ruler or paperback book—and digital tools such as apps.

Medical Professionals Galvanize to Tackle Obesity Pandemic in Malaysia with Release of Revised Clinical Practice Guidelines

WORDS LIM TECK CHOON

We’ve all read about it and probably memorized the statistics by now: Malaysia is among the heaviest countries in Asia, if not the world. Perhaps unsurprisingly, there is also a high prevalence of chronic diseases such as type 2 diabetes, high blood pressure, and others that are linked to obesity.

AN URGENT IMPETUS TO CURB THE OBESITY PANDEMIC IN MALAYSIA

Obesity is classified as a chronic or long-term disease. As such, Malaysian healthcare professionals have banded together in their commitment to provide Malaysians with the best treatment options and accessibility to these treatments.

A milestone in this commitment took place on 9 June 2023, with the release of the 2nd edition of the Clinical Practice Guidelines for the Management of Obesity.

The clinical practice guidelines are jointly published by the Ministry of Health Malaysia, the Malaysian Endocrine & Metabolic Society (MEMS), the Malaysian Society for the Study of Obesity (MASO), the Malaysian Dietitians’ Association (MDA), and Family Medicine Specialists Association of Malaysia (FMSA)—a multidisciplinary collaboration comprising endocrinologists, dietitians, and more.

The launch of the clinical practice guidelines was officiated by Dr Mohd Ridzwan Shahari, the Deputy Director of Medical Development Branch of the Medical Development Division, representing Dato’ Dr Asmayani Khalib, Deputy Director-General of Health (Medical) of the Ministry of Health Malaysia.

AN UPDATED BLUEPRINT OF NEW & ROBUST STRATEGIES TO PREVENT & MANAGE OBESITY

The initial edition of the clinical practice guidelines was released in 2004. With almost 20 years since then, much had changed when it comes to prevalence of, attitude towards, and management approaches for obesity.

As Dr Nurain Mohd Noor the President of MEMS, puts it: “Overweight and obesity in Malaysia is growing with every passing year. Based on the National Health and Morbidity Survey, in 2011, the prevalence was already at 44.5%, and in 2019, it has risen to a staggering 50.1%, whereby half of the population is now classified as overweight or obese.”

As such, the revision of the existing clinical practice guidelines is most timely and necessary. Professor Dr Norlaila Mustafa, Chairperson of the CPG Development Committee, reveals that the committee attracted experts from diverse field—endocrinology, psychology, dietetics, sports medicine, family medicine, paediatric endocrinology—to revise the existing guidelines to incorporate breakthroughs and advances that offer promising solutions in the last 20 years.

Some of the revisions and expansions include:

  • Expanding the range of recommended medications and medical procedures to treat obesity.
  • Updates on medical nutrition therapy to introduce successful and effective changes to a patient’s diet.
  • Emphasis on psychological interventions, such as cognitive behavioural therapy, to motivate patients into adopting and maintaining lifestyle changes to maintain a healthy weight.

With regards to the third point, Prof Dr Norlaila brings up tools include the Binge Eating Scale, which helps to identify individuals with binge eating disorder, ‘SMART’ strategy that aids in a patient’s goal setting, and problem-solving techniques such as ‘IDEAL’ to support patients when faced with setbacks in their weight management journey.

A NEW BASIS FOR BODY MASS INDEX

A key issue raised during the launch was the need for a lower cut-off point for diagnosis of overweight and obesity among Asians.

This is because the current body mass index or BMI system was initially based on the physiology and fat composition of Caucasians.

Asians, on the other hand, typically have shorter height and higher body fat percentages. Research has shown that the risk of type 2 diabetes, high blood pressure, and other weight-associated chronic diseases tend to rise for Asians at a lower BMI point.

Hence, based on evidence gathered from research on Asians, the following BMI categories are recommended for use in Malaysia:

BMI CATEGORY
23 to 27.4 kg/m2 Overweight
27.5 kg/m2 and above Obese
A FOUNDATION FOR A ROLLOUT OF IMPROVED PREVENTION & MANAGEMENT OF OBESITY PROGRAMME IN MALAYSIA

Prof Dr Norlaila shares her hopes that the release of the revised Clinical Practice Guidelines for the Management of Obesity will become a primary cornerstone for treatment and prevention, as well as health awareness programmes in Malaysia.

She reveals that future plans include making weight management and obesity treatment services available in more primary healthcare points such as general practitioners, educational talks and programmes in schools, and more.

Interested healthcare professionals can download a digital copy of the Clinical Practice Guidelines for the Management of Obesity (2nd Edition) at the Academy of Medicine of Malaysia here (link opens in a new tab).

An Endocrinologist Talks About the Thyroid Gland & The Butterfly Effect

WORDS DR KANG WAYE HANN

FEATURED EXPERT
DR KANG WAYE HANN
Consultant Internal Medicine Physician and Endocrinologist
Columbia Asia Hospital Puchong

You are sitting at your work desk, but you can hardly get any work done properly. You struggle to curb the trembling in your fingers.

Sweat trickles down your back. You wonder why it feels this warm despite the air-conditioning blowing at maximum speed.

You swear that you felt a missing beat from the normal pace of your heartbeat. It just feels like there was just something weird with your heartbeat.

Your friends have been complimenting you about how much weight you have lost, but you have a voracious appetite and you keep eating.

Your mercurial mood swings have kept them and other people around you at a distance.

With all these going on, you just could not help thinking, are all these closely related to your scanty and irregular menses? Or is it part and parcel of that smooth neck swelling at your neck and your protruding eyes?

YOU’RE NOT GOING CRAZY—IT COULD BE YOUR THYROID GLAND

If you had experienced any of the symptoms mentioned above, you may have a condition known as hyperthyroidism or thyrotoxicosis.

This is a result of high levels of thyroid hormone, also known as thyroxine, circulating in your blood levels.

An overview of hyperthyroidism. Click the image for a larger, clearer version.

Sitting at the neck and resembling a butterfly, the thyroid gland secretes and stores thyroxine, the hormone that plays a vital role in maintaining your daily metabolism and other bodily functions.

Normally, the levels of the thyroxine hormone are kept in check by your body’s mechanism called homeostasis, with any alterations resulting in compensatory responses in your body.

When this mechanism fails, then the rising thyroxine hormone levels will eventually lead to the symptoms mentioned above.

THE MOST COMMON CAUSE OF HYPERTHYROIDISM IS A ‘GRAVE’ ONE 

Graves’ disease is one of the most common causes of hyperthyroidism.

An overview of Graves’ disease. Click on the image for a larger, clearer version.

In this disease, the tyroxine stimulating hormone-receptor antibodies stimulate the thyroid gland to produce and release high levels of thyroxine into the blood levels.

People with Graves’ disease have smooth neck swelling often accompanied by protruding and swollen eyes as well as skin problems such as hives.

This affliction often plagues women within the reproductive age, especially if they have other autoimmune diseases or family members with autoimmune thyroid diseases.

TOXIC NODULES

Another cause of hyperthyroidism is the presence of thyroid tissue that independently and uncontrollably releases thyroid hormones into the blood stream.

Known as toxic nodules, this disease is more common in the older population, especially those with past history of iodine deficiency.

There can be just a single toxic nodule or multiple toxic nodules in the neck area, giving the appearance of an uneven neck swelling.

At times the neck swelling can be large enough to cause difficulties in swallowing or breathing.

OTHER POSSIBLE CAUSES OF HYPERTHYROIDISM

Other rarer causes include acute infection of the thyroid gland or side effects of certain medications.

IT IS IMPORTANT TO SEE A DOCTOR WHEN YOU THINK YOU HAVE HYPERTHYROIDISM

If left untreated, chronically high levels of thyroid hormones may result in irregular fast beating of the heart and subsequently heart failure.

This may also result in excessive bone mineral loss that can give rise to osteoporosis.

Sometimes, patients with hyperthyroidism may develop a severe life-threatening condition known as a thyroid storm if they are down with other acute medical condition such as a chest infection or heart attack.

A visit to the endocrinologist can be helpful if you think you may have hyperthyroidism, as sometimes the symptoms may be very vague in the early stages.

On top of a clinical assessment, a blood test is necessary to evaluate the thyroid function and confirm high levels of thyroid hormone in the blood.

Aside from that, further tests such as antibody level testing, ultrasound of the neck, or even a radioactive iodine scan are required to determine the exact cause of hyperthyroidism.

THE RIGHT MANAGEMENT PLAN CAN VARY ACCORDING TO THE DIFFERENT CAUSES OF HYPERTHYROIDISM

For instance, patients with Graves’ disease may recover after 18 months of medical treatment. However, patients with toxic nodules usually require life-long medications to control their thyroid hormone levels. In such cases, other options such as surgery and radioactive iodine therapy can be considered.