Determinants of stunting and poor linear growth in children under 2 years of age in India: an in-depth analysis of Maharashtra's comprehensive nutrition survey

Prevalence of stunting and associated factors among under-five children in sub-Saharan Africa: Multilevel ordinal logistic regression analysis modeling

INTRODUCTION

Stunting is still a major public health problem all over the world, it affecting more than one-third of under-five children in the world that leads to growth retardation, life-threatening complication and accelerate mortality and morbidity. The evidence is scarce on prevalence and associated factors of stunting among under-five children in Sub-Saharan Africa for incorporated intervention. Therefore this study aimed to investigate the prevalence and determinants of stunting among under-five children in Sub-Saharan Africa using recent demographic and health surveys of each country.

METHODS

This study was based on the most recent Demographic and Health Survey data of 36 sub-Saharan African countries. A total of 203,852(weighted sample) under-five children were included in the analysis. The multi-level ordinal logistic regression was fitted to identify determinants of stunting. Parallel line (proportional odds) assumption was cheeked by Brant test and it is satisfied (p-value = 0.68) which is greater than 0.05. Due to the nested nature of the dataset deviance was used model comparison rather than AIC and BIC. Finally the adjusted odds ratio (AOR) with 95% CI was reported identify statistical significant determinants of stunting among under-five children.

RESULTS

In this study, the prevalence of stunting among under-five children in Sub-Saharan Africa 34.04% (95% CI: 33.83%, 34.24%) with a large difference between specific countries which ranges from 16.14% in Gabon to 56.17% in Burundi. In the multi-level ordinal logistic regression good maternal education, born from mothers aged above 35 years, high household wealth status, small family size, being female child, being female household head, having media exposure and having consecutive ANC visit were significantly associated with lower odds of stunting. Whereas, living from rural residence, being 24-59 month children age, single or divorced marital status, higher birth order and having diarrhea in the last two weeks were significantly associated with higher odds of stunting.

CONCLUSION

Stunting among under-five children is still public health problem in Sub-Saharan Africa. Therefore designing interventions to address diarrhea and other infectious disease, improving the literacy level of the area and increase the economic level of the family to reduce the prevalence of stunting in the study area.

Underweight and Predictors Among Children Aged 6-59 Months in South Ethiopia

Objectives

Underweight remains the primary public health concern among under-five-year-old children in Ethiopia, despite numerous government-implemented nutrition-specific and sensitive interventions. Therefore, this study aimed to assess underweight and associated factors among children in South Ethiopia.

Methods

Between March and April 2021, 717 children in the South Ari district who were between the ages of 6 and 59 months participated in a cross-sectional study. To choose a sample of households containing a minimum of one child between the ages of 6 and 59 months, a multi-stage sampling procedure was used. Data were collected by interviewer-administered structured questionnaires from the mothers of the children. To determine the factors associated with being underweight, a binary logistic regression analysis was built. All variables with a p-value <0.25 in the bivariable analysis were entered into a multivariable logistic regression analysis. To assess the strength of the association, an adjusted odds ratio (AOR) with a 95% confidence interval was used. With a p-value below 0.05, statistical significance was declared.

Results

The prevalence of underweight was determined to be 29.7% (95% CI: 26.5%, 33.2%). Child age 6-23 months [adjusted odds ratio (AOR) = 0.28; 95% confidence interval (CI): 0.18, 0.44], food insecurity (AOR = 1.48; 95% CI: 1.04, 2.10), sub-optimal child dietary diversity (AOR = 1.44; 95% CI: 1.01, 2.03), birth interval <24 months (AOR = 2.49; 95% CI: 1.75, 3.54), and common childhood illness (AOR = 2.21; 95% CI: 1.52, 3.21) were associated with being underweight.

Conclusion

Underweight among children is predicted by household food insecurity, suboptimal dietary diversity, and common childhood illnesses, necessitating further efforts to improve food security and manage common illnesses.

Global burden and strength of evidence for 88 risk factors in 204 countries and 811 subnational locations, 1990-2021: a systematic analysis for the Global Burden of Disease Study 2021

BACKGROUND

Understanding the health consequences associated with exposure to risk factors is necessary to inform public health policy and practice. To systematically quantify the contributions of risk factor exposures to specific health outcomes, the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2021 aims to provide comprehensive estimates of exposure levels, relative health risks, and attributable burden of disease for 88 risk factors in 204 countries and territories and 811 subnational locations, from 1990 to 2021.

METHODS

The GBD 2021 risk factor analysis used data from 54 561 total distinct sources to produce epidemiological estimates for 88 risk factors and their associated health outcomes for a total of 631 risk-outcome pairs. Pairs were included on the basis of data-driven determination of a risk-outcome association. Age-sex-location-year-specific estimates were generated at global, regional, and national levels. Our approach followed the comparative risk assessment framework predicated on a causal web of hierarchically organised, potentially combinative, modifiable risks. Relative risks (RRs) of a given outcome occurring as a function of risk factor exposure were estimated separately for each risk-outcome pair, and summary exposure values (SEVs), representing risk-weighted exposure prevalence, and theoretical minimum risk exposure levels (TMRELs) were estimated for each risk factor. These estimates were used to calculate the population attributable fraction (PAF; ie, the proportional change in health risk that would occur if exposure to a risk factor were reduced to the TMREL). The product of PAFs and disease burden associated with a given outcome, measured in disability-adjusted life-years (DALYs), yielded measures of attributable burden (ie, the proportion of total disease burden attributable to a particular risk factor or combination of risk factors). Adjustments for mediation were applied to account for relationships involving risk factors that act indirectly on outcomes via intermediate risks. Attributable burden estimates were stratified by Socio-demographic Index (SDI) quintile and presented as counts, age-standardised rates, and rankings. To complement estimates of RR and attributable burden, newly developed burden of proof risk function (BPRF) methods were applied to yield supplementary, conservative interpretations of risk-outcome associations based on the consistency of underlying evidence, accounting for unexplained heterogeneity between input data from different studies. Estimates reported represent the mean value across 500 draws from the estimate's distribution, with 95% uncertainty intervals (UIs) calculated as the 2·5th and 97·5th percentile values across the draws.

FINDINGS

Among the specific risk factors analysed for this study, particulate matter air pollution was the leading contributor to the global disease burden in 2021, contributing 8·0% (95% UI 6·7-9·4) of total DALYs, followed by high systolic blood pressure (SBP; 7·8% [6·4-9·2]), smoking (5·7% [4·7-6·8]), low birthweight and short gestation (5·6% [4·8-6·3]), and high fasting plasma glucose (FPG; 5·4% [4·8-6·0]). For younger demographics (ie, those aged 0-4 years and 5-14 years), risks such as low birthweight and short gestation and unsafe water, sanitation, and handwashing (WaSH) were among the leading risk factors, while for older age groups, metabolic risks such as high SBP, high body-mass index (BMI), high FPG, and high LDL cholesterol had a greater impact. From 2000 to 2021, there was an observable shift in global health challenges, marked by a decline in the number of all-age DALYs broadly attributable to behavioural risks (decrease of 20·7% [13·9-27·7]) and environmental and occupational risks (decrease of 22·0% [15·5-28·8]), coupled with a 49·4% (42·3-56·9) increase in DALYs attributable to metabolic risks, all reflecting ageing populations and changing lifestyles on a global scale. Age-standardised global DALY rates attributable to high BMI and high FPG rose considerably (15·7% [9·9-21·7] for high BMI and 7·9% [3·3-12·9] for high FPG) over this period, with exposure to these risks increasing annually at rates of 1·8% (1·6-1·9) for high BMI and 1·3% (1·1-1·5) for high FPG. By contrast, the global risk-attributable burden and exposure to many other risk factors declined, notably for risks such as child growth failure and unsafe water source, with age-standardised attributable DALYs decreasing by 71·5% (64·4-78·8) for child growth failure and 66·3% (60·2-72·0) for unsafe water source. We separated risk factors into three groups according to trajectory over time: those with a decreasing attributable burden, due largely to declining risk exposure (eg, diet high in trans-fat and household air pollution) but also to proportionally smaller child and youth populations (eg, child and maternal malnutrition); those for which the burden increased moderately in spite of declining risk exposure, due largely to population ageing (eg, smoking); and those for which the burden increased considerably due to both increasing risk exposure and population ageing (eg, ambient particulate matter air pollution, high BMI, high FPG, and high SBP).

INTERPRETATION

Substantial progress has been made in reducing the global disease burden attributable to a range of risk factors, particularly those related to maternal and child health, WaSH, and household air pollution. Maintaining efforts to minimise the impact of these risk factors, especially in low SDI locations, is necessary to sustain progress. Successes in moderating the smoking-related burden by reducing risk exposure highlight the need to advance policies that reduce exposure to other leading risk factors such as ambient particulate matter air pollution and high SBP. Troubling increases in high FPG, high BMI, and other risk factors related to obesity and metabolic syndrome indicate an urgent need to identify and implement interventions.

FUNDING

Bill & Melinda Gates Foundation.

Influence of maternal and neonatal continuum of care on the risk of intergenerational cycle of stunting: a cross-sectional study

OBJECTIVES

This study aimed to analyse the influence of the continuum of care during pregnancy and neonatal periods on the risk of intergenerational cycle of stunting.

DESIGN

This study was a cross-sectional study, with data analysed from the 2018 Basic Health Research in Indonesia.

SETTINGS

Basic Health Research 2018 was conducted throughout 513 cities/regencies in 34 provinces in Indonesia. The households were selected through two-stage sampling methods. First, census blocks (CB) were selected using probability proportional to size methods in each urban/rural stratum from each city/regency. Ten households were then selected from each CB using systematic sampling methods. All family members of the selected households were measured and interviewed.

PARTICIPANTS

This study analyses 31 603 children aged 0-24 months.

OUTCOMES MEASURES

The dependent variable was the risk of the intergenerational cycle of stunting. Mothers who had a height less than 150.1 cm (short stature mothers) and had children (≤ 24 months of age) with length-for-age Z-score less than -2 Standard Deviation (SD) of the WHO Child Growth Standard (stunted children) were defined as at risk of the intergenerational cycle of stunting.

RESULTS

Mothers with incomplete maternal and neonatal care visits were 30% more likely to be at risk on the intergenerational cycle of stunting (OR (95% CI): 1.3 (1.00 to 1.63)) after adjusting for economic status.

CONCLUSION

The continuum of maternal and neonatal healthcare visits could potentially break the intergenerational cycle of stunting, especially in populations where stunted mothers are prevalent.

Creating culturally-informed protocols for a stunting intervention using a situated values-based approach (WeValue InSitu): a double case study in Indonesia and Senegal

International development work involves external partners bringing expertise, resources, and management for local interventions in LMICs, but there is often a gap in understandings of relevant local shared values. There is a widespread need to better design interventions which accommodate relevant elements of local culture, as emphasised by recent discussions in global health research regarding neo-colonialism. One recent innovation is the concept of producing 'cultural protocols' to precede and guide community engagement or intervention design, but without suggestions for generating them. This study explores and demonstrates the potential of an approach taken from another field, named WeValue InSitu, to generate local culturally-informed protocols. WeValue InSitu engages stakeholder groups in meaning-making processes which 'crystallize' their envelope of local shared values, making them communicable to outsiders.Our research context is understanding and reducing child stunting, including developing interventions, carried out at the Senegal and Indonesia sites of the UKRI GCRF Action Against Stunting Hub. Each national research team involves eight health disciplines from micro-nutrition to epigenetics, and extensive collection of samples and questionnaires. Local culturally-informed protocols would be generally valuable to pre-inform engagement and intervention designs. Here we explore generating them by immediately following the group WeValue InSitu crystallization process with specialised focus group discussions exploring: what local life practices potentially have significant influence on the environments affecting child stunting, and which cultural elements do they highlight as relevant. The discussions will be framed by the shared values, and reveal linkages to them. In this study, stakeholder groups like fathers, mothers, teachers, market traders, administrators, farmers and health workers were recruited, totalling 83 participants across 20 groups. Themes found relevant for a culturally-informed protocol for locally-acceptable food interventions included: specific gender roles; social hierarchies; health service access challenges; traditional beliefs around malnutrition; and attitudes to accepting outside help. The concept of a grounded culturally-informed protocol, and the use of WeValue InSitu to generate it, has thus been demonstrated here. Future work to scope out the advantages and limitations compared to deductive culture studies, and to using other formative research methods would now be useful.

Estimating minimum dietary diversity for children aged 6-23 months: a comparison of agreement and cost of two recall methods in Cambodia and Zambia

OBJECTIVE

To compare the agreement and cost of two recall methods for estimating children's minimum dietary diversity (MDD).

DESIGN

We assessed child's dietary intake on two consecutive days: an observation on day one, followed by two recall methods (list-based recall and multiple-pass recall) administered in random order by different enumerators at two different times on day two. We compared the estimated MDD prevalence using survey-weighted linear probability models following a two one-sided test equivalence testing approach. We also estimated the cost-effectiveness of the two methods.

SETTING

Cambodia (Kampong Thom, Siem Reap, Battambang, and Pursat provinces) and Zambia (Chipata, Katete, Lundazi, Nyimba, and Petauke districts).

PARTICIPANTS

Children aged 6-23 months: 636 in Cambodia and 608 in Zambia.

RESULTS

MDD estimations from both recall methods were equivalent to the observation in Cambodia but not in Zambia. Both methods were equivalent to the observation in capturing most food groups. Both methods were highly sensitive although the multiple-pass method accurately classified a higher proportion of children meeting MDD than the list-based method in both countries. Both methods were highly specific in Cambodia but moderately so in Zambia. Cost-effectiveness was better for the list-based recall method in both countries.

CONCLUSION

The two recall methods estimated MDD and most other infant and young child feeding indicators equivalently in Cambodia but not in Zambia, compared to the observation. The list-based method produced slightly more accurate estimates of MDD at the population level, took less time to administer and was less costly to implement.

Analysis of traditional feeding practices and stunting among children aged 6 to 59 months in Karanganyar District, Central Java Province, Indonesia

BACKGROUND

Traditional feeding practices are widespread in Indonesia. Therefore, using traditional feeding practices commonly used among mothers, this study examined the association between these practices and stunting along with other relevant factors (i.e., sociodemographic factors, feeding practices, vaccination status, and place of residence).

METHODS

This cross-sectional study was conducted in Karanganyar District, Central Java Province. Data from a total of 706 children aged 6 to 59 months (352 children with stunting and 354 children without stunting) were obtained from the medical records of 10 primary health care units (PHCUs) in 9 subdistricts. Descriptive analysis and binary logistic regression (BLR) were performed to explore the association between the dependent (stunting) and independent variables.

RESULTS

The BLR results from children 6 to 59 months indicated that children of mothers with food restrictions during pregnancy (AOR = 5.87, 95% CI: 3.03, 11.38), children with prelacteal feeding (AOR = 4.27, 95% CI: 2.16, 8.41) and children with food restrictions (AOR = 7.74, 95% CI: 1.22, 49.16) were more likely to experience stunting. Those from children 6 to 23 months revealed that food restrictions during pregnancy (AOR = 17.55, 95% CI: 2.86, 107.80) and prelacteal feeding (AOR = 10.58, 95% CI: 2.06, 54.41) were related to stunting. The reasons for traditional feeding practices were related to cultural beliefs. For example, mothers believed that red meat could cause high blood pressure; thus, the consumption of red meat could trigger miscarriage or bleeding during delivery. In addition, this study showed that low sociodemographic status, inappropriate feeding practices, incomplete vaccination, and residence in rural areas were related to stunting.

CONCLUSIONS

The findings reflect the importance of education for mothers to correct misconceptions of traditional feeding practices. The government should strengthen counseling services in PHCUs to improve mothers' knowledge of and attitudes toward appropriate feeding practices. Additionally, public relations practices through the mass media should continue for family members, especially senior members, as they influence mothers' autonomy in decision-making regarding feeding practices in Indonesia.

First foods in a packaged world: Results from the COMMIT consortium to protect young child diets in Southeast Asia

Although commercially produced complementary foods (CPCFs) are increasingly sold throughout Southeast Asia, concerns have been raised about CPCFs nutritional quality, labelling practices and the strength and scope of national CPCF regulations. The Consortium for Improving Complementary Foods in Southeast Asia (COMMIT), composed of UN agencies and civil society organizations, was formed to assess the nutrient gap in the diets of young children and the consumer, product and policy landscapes for CPCFs in seven Southeast Asian countries. Results from a nutrient gap assessment indicate that the diets of children aged 6-23 months are suboptimal and deficient in micronutrients. A consumer survey revealed that caretakers commonly use CPCFs, are conscious of the importance of nutrition and are influenced by label claims. Results from a CPCF benchmarking showed that many products sold in Southeast Asia contained added sugar or sweeteners, had a high total sugar and/or high sodium content and that no CPCF product adhered to all recommended labelling practices. Further, a legal review of national binding legal measures relevant to CPCFs showed minimal alignment with available global guidance. Urgent actions are necessary to strengthen national regulations related to CPCF nutrient composition and labelling practices. To speed progress, COMMIT developed a compendium of existing standards and global guidance to help countries align their national regulations with CPCF composition, labelling and production recommendations. Advocacy to garner public support for new or improved CPCF regulations, as well as strong government monitoring and enforcement of regulations, is crucial to support efforts to safeguard and improve the diets of older infants and young children in Southeast Asia.

Safely managed sanitation practice and childhood stunting among under five years old children in Myanmar

In 2020, 149 million children under the age of five were estimated to be stunted globally. Around half of deaths among children under 5 years of age are related to under-nutrition. Objective of this study is to determine the association between safely managed sanitation and childhood stunting among under-five years old children in Myanmar. This cross-sectional analytical study was conducted in 16 townships across three regions and five states in Myanmar. Multiple logistic regressions analysis was performed to determine the associations. This study found that 327 (27.09%) under-five children were stunted among a total of 1207 children in Myanmar. Children with unsafely managed sanitation were 2.88 times more likely to be stunting compared with children who access to safely managed sanitation services (AOR = 2.88, 95% CI: 2.16 to 3.85; p-value <0.01). Other associated factors for childhood stunting were needs 1-15 minutes for water collection (AOR = 2.07, 95% CI: 1.46 to 2.94; p-value <0.01), 15-60 minutes for water collection times (AOR = 1.55, 95% CI: 1.08 to 2.23; p-value 0.02), improper waste water disposal (AOR = 1.99, 95% CI: 1.47 to 2.70; p-value <0.01), boys children (AOR = 4.49, 95% CI: 3.30 to 6.12; p-value <0.01), did not take vitamin A supplements(AOR = 1.64, 95% CI: 1.22 to 2.20; p-value <0.01), mothers height shorter than 153.4cm (AOR = 1.94, 95% CI: 1.45 to 2.58; p-value <0.01), and the lower minimal diet diversity (AOR = 1.47, 95% CI: 1.08 to 2.01; p-value 0.02). More access to safely managed sanitation facilities, technical sharing for proper waste water disposal, promoting household water supply system, health promotion for children's diet eating pattern, and regular support for Vitamin A supplementation are critical to reduce childhood stunting among children under the age of five in Myanmar.

Prevalence of Stunting and its Biosocial Determinants among Young Children Enrolled at Urban Anganwadi Centers in Rishikesh, Uttarakhand

Background

Stunting is a significant public health problem in childhood in developing countries. Sustainable Developmental Goals have mandated that each country reduce stunting by 50% by 2030. However, despite various nutrition and health programs, India still faces a massive burden of stunting. With the increasing urbanization in the country and its typical challenges related to health and nutrition, chronic malnutrition is a massive problem in urban areas, especially among people in the lower wealth quintile. Hence, current study has attempted to estimate the prevalence of stunting among children (0-6 years) and its determinants.

Methodology

A cross-sectional study was conducted in the Urban Anganwadi centers of Rishikesh, Uttarakhand, for 6 months, from December 2021 to May 2022. Three hundred ten children from 13 selected Anganwadi centers were included using random sampling. Data were collected using a semi-structured validated and pretested questionnaire using Epicollect 5.0. Data were analyzed using the SPSS 23.0 version to estimate the prevalence of stunting and associated risk factors.

Results

Out of 310 participants, 71 (22.9%) were stunted. Female children were slightly more stunted (24.7%) than males (21.1%). Maximum stunting (33.4%) was observed among children in the 5-6-year age group, and children with higher birth order were much more stunted. Stunting was reported more in children who were breastfed on demand (33.8%) than those fed every 2 hours (19.3%).

Conclusion

Stunting prevalence in urban areas of Rishikesh is 22.9%, which is almost similar to the state average of 24.3% for urban areas; however, it was higher in comparison to the SDG 2030 global target of ending malnutrition of all forms. Stunting was significantly associated with feeding on demand and eating frequency less than twice a day.

Association of access to water, sanitation and handwashing facilities with undernutrition of children below 5 years of age in Bangladesh: evidence from two population-based, nationally representative surveys

OBJECTIVE

To examine the association between household access to water, sanitation and handwashing (WaSH) facilities and child undernutrition in Bangladesh.

DESIGN, SETTING AND PARTICIPANTS

Cross-sectional study of children less than 5 years using data collected from the 2019 Multiple Indicator Cluster Survey (MICS) and the 2017-2018 Bangladesh Demographic and Health Survey (BDHS).

OUTCOME MEASURES

Stunting, wasting and underweight, defined as a Z-score <-2 SD for height-for-age, weight-for-height and weight-for-age, respectively. We applied hierarchical multiple binary logistic regression models.

RESULTS

Among 30 514 children 0-59 months, there was a high prevalence of child undernutrition (MICS: 28.0% stunted, 9.8% wasted, 22.6% underweight; BDHS: 30.8% stunted, 8.4% wasted, 21.7% underweight). Most children came from households lacking basic sanitation (MICS: 39.1%, BDHS: 55.3%) or handwashing facilities (MICS: 43.8%, BDHS: 62.6%). Children from households without access to WaSH facilities experienced the highest rates of undernutrition. Exposure-specific adjusted logistic regression models showed that a lack of access to improved water sources was associated with greater odds of wasting (MICS: adjusted OR (AOR) 1.36, 95% CI 1.00 to 1.85, p<0.05); basic sanitation facility with higher rates of stunting (MICS: 1.13, 1.04 to 1.23, p<0.01) and underweight (BDHS: 1.18, 1.02 to 1.37, p<0.05); and a lack of handwashing facilities with stunting (BDHS: 1.27, 1.10 to 1.48, p<0.01) and underweight (MICS: 1.10, 1.01 to 1.19, p<0.05). In fully adjusted models, no basic sanitation facility was associated with higher odds of stunting (MICS: AOR 1.12, 1.03 to 1.22, p<0.01) and a lack of handwashing facilities with higher odds of underweight (BDHS: AOR 1.30, 1.10 to 1.54, p<0.01;MICS: AOR 1.09, 1.01 to 1.19, p<0.05).

CONCLUSION

These findings demonstrate a significant association between poor household WaSH facilities and high prevalence of child undernutrition. Improving WaSH may help reduce child undernutrition in Bangladesh.

Factors associated with wasting and stunting among children aged 06-59 months in South Ari District, Southern Ethiopia: a community-based cross-sectional study

BACKGROUND

Child undernutrition is a major public health problem in Ethiopia despite different nutrition-specific and sensitive interventions implemented by the government. However, evidence regarding the burden and responsible factors is limited in the South Ari district. Hence, this study aimed to assess factors associated with wasting and stunting among children aged 06-59 months in the South Ari district, Southern Ethiopia, 2021.

METHODS

A community-based cross-sectional study was conducted from March 11 to April 11, 2021, among 717 households with at least one child aged 06-59 months. Anthropometric measurements were taken using standard procedures and were converted to height for age Z score and weight-for-height using WHO Anthro software Version 3.2.2. Data were checked and entered into Epi-Data Version 3.1 and analyzed using SPSS Version 25.0. Binary logistic regression analysis was fitted to identify predictors of wasting and stunting. A p-value < 0.05 was used to declare statistical significance.

RESULT

The prevalence of wasting and stunting among children aged 06-59 months in the district was 9.1% (95% CI: 7.07%, 11.41%) and 59.97% (95% CI: 56.28%, 63.58%), respectively. Family size (8 and above) (AOR = 3.03, 95% CI: 1.31, 7.03), family size (5 to 7) (AOR = 2.05, 95% CI: 1.11, 3.81), poor and medium wealth index (AOR = 3.69, 95% CI: 1.65, 8.26) and (AOR = 2.29, 95% CI: 1.01, 5.16), insufficient maternal knowledge on child feeding practice (AOR = 2.58, 95% CI: 1.31, 5.07), presence of diarrhea in the past two weeks (AOR = 2.05, 95% CI: 1.10, 3.85), non-exclusive breastfeeding (AOR = 2.65, 95% CI: 1.51, 4.65), and birth interval of < 24 months (AOR = 4.49, 95% CI: 2.40, 8.37) were factors significantly associated with wasting. Whereas, children in the age group of 24-59 months (AOR = 2.24, 95% CI: 1.58, 3.16), non-exclusive breastfeeding (AOR = 1.81, 95% CI: 1.24, 2.65), birth interval of fewer than 24 months (AOR = 1.54, 95% CI: 1.11, 2.14), sub-optimal child dietary diversity score (AOR = 1.59, 95% CI: 1.14, 2.22), being a non-beneficiary of productive safety-net program (AOR = 1.91, 95% CI: 1.24, 2.95), and household food insecurity (AOR = 2.60, 95% CI: 1.86, 3.64) were factors significantly associated with stunting.

CONCLUSIONS

Wasting and stunting were found to be key public health problems in the South Ari District. Hence, further interventions should consider strategies to enhance household food security and integration of productive safety net programs with primary health care services. Rigorous work is required in advocating and strengthening the provision of family planning services, child care, and integrated management of common childhood illnesses. Moreover, behavioral change communication is highly demanded to improve child feeding practices.

Age-appropriate feeding practices and their association with undernutrition among children aged 6-23 months in aspirational districts of India: a multinomial analysis

'Health and nutrition' is one among the five areas covered by the Aspirational District Programme in India, which aims to achieve the Sustainable Development Goals (SDGs). The reduction of undernutrition in under-five children has remained a major focus of the SDGs, especially at the ages of 6-23 months as this affects child development. This study used National Family Health Survey 2015-16 data to examine appropriate feeding practices and their associations with undernutrition among children aged 6-23 months in the 124 aspirational districts of India. Multinomial logistic regression analysis was used to analyse the association between feeding practices and undernutrition, adjusting for covariates. A total of 13,851 children aged 6-23 months were included in the analysis. Child nutritional outcomes, and children receiving the recommended minimum dietary diversity (MDD), minimum meal frequency (MMF) and minimum acceptable diet (MAD), were poorer in the aspirational compared with non-aspirational districts. However, the proportions of children who continued to breastfed, i.e. currently breastfeeding and the proportion of children who were receiving appropriate breastfeeding, i.e. receiving complementary feeding, in addition to breast milk, were higher in the aspirational districts. Appropriate breastfeeding and MDD were found to be associated negatively with undernutrition. While the continuation of breastfeeding increased the odds of children being undernourished, appropriate breastfeeding lowered the odds. The significant predictors of undernourishment among the study children were the child being male, of higher birth order, older and of smaller than average birth size; mother's lower educational level, mother's lower BMI of mothers and being a teenage mother; and poor household drinking water, sanitation facilities and lower economic status. This study suggests that educating mothers, especially illiterate and poor mothers, about appropriate breastfeeding and dietary diversity could help prevent and reduce child undernutrition in the aspirational districts of India.

Stunting and associated factors among children aged 6–59 months from productive safety net program beneficiary and non-beneficiary households in Meta District, East Hararghe zone, Eastern Ethiopia: a comparative cross-sectional study

Background

Undernutrition is one of the major public health problems affecting children in developing settings. Despite impressive interventions like productive safety net program (PSNP), there is limited information on the association between stunting and PSNP implementation in Ethiopia.

Methods

Community-based comparative cross-sectional study design was used among systematically selected 1555 children and their mothers/caregivers from households enrolled in PSNP and not, respectively, in Meta District east Ethiopia from 5th–20th of March 2017. Data were collected using pretested structured questionnaire. Measuring board was used to measure length/height of children. Length/height for age Z-score was generated using World Health Organization (WHO) Anthro version 3.2.2. Descriptive statistics was used to describe all relevant variables. Bivariable and multivariable logistic regression analyses were used to identify predictors of stunting. Odds ratio along with 95% confidence intervals were estimated to measure the strength of association. The statistical significance was declared at p value less than 0.05.

Results

The prevalence of stunting was 47.7%, 95% CI (44.1%, 51.5%) and 33.5%, 95% CI (29.9%, 36.9%) among children from households enrolled in PSNP and non-PSNP ones, respectively. Lack of maternal education [AOR = 3.39; 95% CI (1.12, 5.11)], women’s empowerment [AOR = 3.48; 95% CI (2.36, 5.12)] and fourth antenatal care visit [AOR = 4.2, 95% CI (2.5, 6.8)], practicing hand washing [AOR = 0.46; 95% CI (0.28, 0.76)], living in mid-land [AOR = 1.94, 95% CI (1.12, 3.35)] and low-land[AOR = 0.27: 95% CI (0.16, 0.45)] agro-ecological zones, PSNP membership [AOR = 1.82, 95% CI (1.14, 2.89)], childhood illness [AOR = 8.41; 95% CI (4.58, 12.76)], non-exclusive breastfeeding [AOR = 3.6; 95% CI (2.30, 4.80)], inadequate minimum dietary diversity [AOR = 4.7; 95% CI (3.0, 7.40)], child’s sex [AOR = 1.73, 95% CI (1.18, 2.53)] and age (24–59 months) [AOR = 3.2; 95% CI (1.6, 6.3)] were independent predictors of stunting.

Conclusions

The prevalence of stunting was high among children from households enrolled in PSNP. Stunting was significantly associated with maternal- and child-related factors. Therefore, women empowerment on household’s issues and improving infant and young child feeding practices could reduce the prevalence of stunting and its adverse consequences.

Impact of a homestead food production program on women's empowerment: Pro-WEAI results from the FAARM trial in Bangladesh

Nutrition-sensitive agricultural programs have the potential to improve women's and children's nutrition, along with women's empowerment. The project-level Women's Empowerment in Agriculture Index (pro-WEAI) aims to standardize the measurement of women's agency and enable the assessment of impact over typical project timelines. Within the Food and Agricultural Approaches to Reducing Malnutrition (FAARM) cluster-randomized controlled trial in rural Habiganj, Sylhet, Bangladesh, we examined quantitative pro-WEAI data collected from a subsample of trial participants and their husbands (n = 885) approximately four months after the end of the intervention. We evaluated the impact of a three-year homestead food production program on men's and women's agency separately by pro-WEAI domain and indicator, using multilevel logistic and linear regression. We show that women in the FAARM intervention group had levels of agency similar to men and much higher than women in the control group (Odds Ratio [OR] 7.7, p < 0.001), corresponding to better gender equity in intervention areas (OR 3.5, p < 0.001). The higher levels of agency among intervention women were driven by greater intrinsic and collective agency but not by instrumental agency. Compared to controls, more women in the intervention group found intimate partner violence unacceptable (OR 3.5, p < 0.001), had greater ownership of assets (OR 2.6, p = 0.001), better control of income (OR 1.8, p = 0.042), higher levels of group membership (OR 14.0, p < 0.001), and membership in groups they considered influential (OR 166.8, p < 0.001). Self-efficacy was greater in intervention areas for both women (OR 3.2, p < 0.001) and men (OR 2.3, p = 0.002). Our results contribute to the development of benchmarks for interpreting pro-WEAI scores across programs. Our assessment of the impact of a homestead food production program on women's agency provides additional rationale for women-led agricultural projects. We plan to build on these findings by examining the role of improved women's agency on the pathway from the intervention to nutritional impacts.

Prevalence and associated risk factors of chronic malnutrition amongst children under five in Eswatini

Background

About 20 million children under fi-ve in Southern Africa have chronic malnutrition. This study determines the prevalence of chronic malnutrition and associated risk factors amongst children under five.

Aim

To determine the proportion of children with chronic malnutrition and investigate associated risk factors of chronic malnutrition.

Setting

The study was conducted in communities in the four regions of Eswatini.

Methods

This study is a retrospective cross-sectional study that used data from a Multiple Indicator Cluster Survey (MICS) conducted in 2014. The study involved 3261 children who are under 5 years of age. Data on nutritional status and household characteristics were used. Logistic regression was used to identify factors associated with chronic malnutrition in the univariable and multivariable models, respectively.

Results

Results showed that 18.1% (confidence interval [CI]: 18.5–21.5) of children under five have chronic malnutrition. The highest prevalence was 20.8% (CI: 17.4–24.7) in the Shiselweni region, followed by the Manzini region with 17.6% (CI: 14.5–21.1) and the Lubombo region with 17.2% (CI: 13.9–21.2). The lowest prevalence of chronic malnutrition at 16.7% (CI: 13.6–20.3) was the Hhohho region. The results indicated that low birth weight (odds ratio [OR] = 4.63, CI: 1.12–19.2), mothers’ lack of education (OR = 1.50, CI: 1.04–2.17) and children aged 12–24 months (OR = 1.28, CI: 0.88–1.87) were significantly associated with chronic malnutrition.

Conclusion

The findings showed that malnutrition is an important public health problem in children under five and needs a multisectoral response. Low birth weight, mothers’ education and the child’s age are risk factors associated with chronic malnutrition.

Contribution

The results inform evidence-based programming for the prevention of chronic malnutrition in children thus assist the country to meet sustainable development goals.

Potential of Nile Tilapia (Oreochromis niloticus) as an Alternative Complementary Food Ingredient for Stunting Children

BACKGROUNDS:The Result of the Basic Health Research 2018 stunting prevalence in Indonesia is 30.8%. One of the potential local foodstuffs in Indonesia is nile Tilapia fish (Oreochromis niloticus). Nile Tilapia fish has a high nutrient content, especially protein, calcium and monounsaturated fatty acids. OBJECTIVES: Analyzed of nutrient content and heavy metal content of lead in Nile Tilapia. METHODS:The study was a laboratory study using raw materials of Nile Tilapia fish . Then analyzed the content of proximate, fatty acids, amino acids and lead heavy metals. Statistical tests use descriptive tests. RESULTS:The total protein content of 18.46 grams, and the calcium content of 74.38 grams in 100 grams of material. Total fatty acids of Nile Tilapia 30.39%, Palmitic acid 7.87%, stearic acid 4.30%, oleic acid 8.13%, Linoleic Acid 3.67% of total fatty acids. Total amino acids is 21.56%, Arginine 1.88%, Leucine 1.69%, Lysine 1.84%, Aspartic Acid 2.16%, Glutamic Acid 3.45% of the total amino acids. CONCLUSION:High nutrient content in Nile Tilapia are proteins, calcium, oleic fatty acids, palmitic, linoleic and stearic acids. The highest amino acids are aspartic acid, glutamic acid, lysine arginine and leucine.

Complementary Feeding Practices among Young Children in China, India, and Indonesia: A Narrative Review

Under- and overnutrition are co-existing health issues in several countries across Asia. Poor complementary feeding (CF) is a significant determinant of malnutrition in children and a major cause of morbidity and mortality. The purpose of this narrative review is to summarize the most recent evidence regarding the CF practices in 3 countries with a high prevalence of stunting and overweight, and currently undergoing rapid economic and nutritional transition: China, India, and Indonesia. We focused particularly on the adequacy of CF, based on the WHO feeding indicators (2021) regarding timing, frequency, diversity, as well as the consumption of specific food groups. According to the findings, the majority of infants in the 3 countries are introduced to CF at an inappropriate time: either too early (particularly in urban/rural areas of China and Indonesia) or too late (India) compared with the WHO recommendation. Furthermore, in all countries, diets are characterized by a low variety and frequency of CF and consist mainly of staple foods with poor nutritional quality, such as rice, cereals, or noodles. Nutrient-dense and protein-rich foods, such as foods of animal origin, are either inadequately consumed (rural areas of China and India) or introduced too late (urban areas of China and Indonesia) in the diets of children. In all countries, the consumption of fruit and vegetables, especially during the early CF period, is poor. In contrast, a significant proportion of both urban and rural children, particularly in Indonesia and India, are consuming energy-dense/nutrient-poor snacks and sugary drinks during the CF period. The described practices may pose a significant risk for the development of energy and/or nutrient gaps, magnifying the double and triple burden of malnutrition present in these countries. Further research is warranted to understand the significance of the observed practices for stunting and/or overweight/obesity risk.

Low Fruit and Vegetable Consumption Associated with Linear Growth Faltering among Children in Urban Bangladesh

The objective of this study was to examine the association between dietary diversity and child growth among children 6 to 23 months of age in urban slums of Bangladesh. This prospective cohort study enrolled 192 participants 6 to 23 months of age in Dhaka, Bangladesh. A total of 170 children with follow-up anthropometric data were included in the analysis. To collect dietary intake information for children 6 to 23 months of age, consumption of five or more of the following eight minimum dietary diversity food groups was recorded using 24-hour dietary recall at enrollment provided by the child's caregiver: 1) breast milk; 2) grains, roots, and tubers; 3) legumes and nuts; 4) dairy products; 5) flesh foods; 6) eggs; 7) vitamin A-rich fruits and vegetables; and 8) other fruits and vegetables. Height and weight were measured at baseline and at a 12-month follow-up. Fifty-five percent of children (106 of 192) consumed five or more of the eight minimum dietary diversity food groups during their first visit to assess dietary intake. Eighty-two percent of children (157 of 192) had a report of consuming an animal source of food (e.g., eggs, diary, flesh foods) in the past 24 hours, 85% (164 of 192) consumed any source of protein (e.g., eggs, diary, flesh foods, nuts, and legumes), and 65% of children (125 of 192) were reported to consume any fruits and vegetables. Child consumption of fruits and vegetables was associated positively with change in length-for-age z-scores from baseline to the 12-month follow-up (coefficient, 0.86; 95% CI, 0.03-1.68). Inadequate fruit and vegetable consumption was associated with linear growth faltering among the young children residing in urban Dhaka, Bangladesh. These findings demonstrate the need for effective interventions to increase fruit and vegetable consumption in this susceptible pediatric population.

The feasibility of using life skills training in primary schools to improve mental health and academic performance: a pilot study in Kenya

BACKGROUND

There is no Kenyan evidence on the relationship between mental illness and academic performance. We aimed to determine the effect of life skills training on mental health and academic performance.

METHODS

We administered to 1848 primary school children a researcher designed socio-demographic questionnaire, and the Youth Self Report (YSR) and Child Behavior Checklist (CBCL) to their parents, followed by eight sessions of life skills training. We extracted data from the individual records of each child on overall performance pre and post training separated by one year. We conducted descriptive statistics, paired sample t-tests, multivariate linear regression analysis and linear mixed model analysis to assess changing patterns of academic performance and any predictive characteristics.

RESULTS

There was significant (p < 0.05) improvement in overall academic performance (aggregate marks and all individual subjects) for both lower primary and upper primary classes after the life-skills training intervention. For lower classes (2-4 grades) increase in academic performance was significantly associated with fathers and mothers education levels, region and class. For upper classes, (5-7 grades) increase in academic performance was associated with region, class and age.

CONCLUSIONS

Life skills training is recommended as it could improve academic performance, but predicted by socio-demographic factors.

The effect of convergent action on reducing stunting prevalence in under-five children in Banggai District, Central Sulawesi, Indonesia

OBJECTIVE

This study aimed to assess the amount of changes in prevalence of stunting after one-year convergence intervention.

METHODS

This was an evaluation study of national program that implemented in Banggai District beginning 2018. There were ten villages (n=532) that included in the program based on severity of stunting prevalence. Data were analyzed using chi-square and independent t-test using SPSS.

RESULT

After a year program, stunting reduced to 38.91% or 2.18% from the baseline (41.09%). The highest reduction was in at 0-5 mo (8.59%) and 6-11 mo (8.46%). There was no difference using height for age z-score in all ages (-1.64±1.19 to -1.59±1.38, p=0.506). However, the reduction was significant at 0-11 months (-1.20±1.23 to 0.78±1.58, p=0.020) but no in other age categories (p>0.05).

CONCLUSION

The convergence action for one year intervention reduced significantly stunting in 0-11 months of children but not in other age categories of under five children.

Household Food Insecurity, Dietary Diversity, and Stunting in Sub-Saharan Africa: A Systematic Review

BACKGROUND

The significant public health problem in Sub-Saharan Africa of household food insecurity is an underlying cause of malnutrition in Sub-Saharan Africa. This study aims to systematically study the association between household food insecurity, dietary diversity, and stunting.

METHODS

This review was carried out based on the recommendations of PRISMA (2015). We searched the literature in six bibliographic databases: PubMed, EMBASE, Science Direct, Web of Science, Google Scholar, and Scopus. The research was based on studies conducted in Sub-Saharan Africa about household food insecurity, dietary diversity, and stunting and was published between 2009 and 2020.

RESULTS

Out of 2398 original articles identified, only 21 articles met the specific requirements of this review. Two-thirds of the articles selected showed that stunting was linked to household food insecurity and dietary diversity.

CONCLUSIONS

This study found that household food insecurity and dietary diversity are significantly associated with stunting in Sub-Saharan Africa. This review recommends that in order to yield a sustainable fight against childhood malnutrition in Sub-Saharan Africa, reliable guidelines and strategies are needed to address these factors related to malnutrition.

Effects of dietary and health factors on nutritional status of children in pastoral settings in Borana, southern Ethiopia, August-October 2015

BACKGROUND

Childhood undernourishment is a major public health problem globally, and being responsible for higher mortalities in children and enormous health costs in sub-Saharan Africa. However, scarcity of data on the magnitude of malnutrition and its underlying causes, especially in the pastoral system, limits the effectiveness of potential interventions. This study addresses the nutritional status and factors associated with malnutrition among children in Borana pastoral system, southern Ethiopia.

METHODS

A community based cross-sectional study, using multistage cluster sampling, was conducted from August to October 2015. Dietary diversity score (DDS), milk and meal frequencies, anthropometric measurements, and socio-economic variables were recorded for 538 children aged 6-59 months. Multivariable generalized linear model (GLM) with log link function was applied to ascertain determinants of malnutrition. The strength of association was assessed based on prevalence ratio (PR).

RESULTS

Prevalence of underweight, stunting, and wasting were 28.3 % (95 % CI: 24.4-32.1), 41.1 % (95 % CI: 36.7-45.1), and 9.8 % (95 % CI: 7.3, 12.4), respectively. Children who consumed more diverse foods were at a lower risk of being underweight (PR = 0.72, 95 % CL: 0.59-0.88), stunted (PR = 0.80, 95 % CL: 0.68-0.93) and wasted (PR = 0.42, 95 % CL: 0.27-0.66). Intake of increased milk frequency was also associated with lower risk of underweight (PR = 0.86, 95 %CL: 0.76-0.97), stunting (PR = 0.83, 95 %CL: 0.75-0.91) and wasting (PR = 0.73, 95 %CL: 0.56-0.96). The risk of underweight (PR = 1.02, 95 %CL: 1.01-1.03), stunting (PR = 1.01, 95 %CL: 1.00-1.02) and wasting (PR = 1.01, 95 %CL: 1.00-1.04) had increased with age, and no difference was observed between boys and girls. Children who lived far away from health care facilities were 1.2 and 2.4 times more likely to be stunted and wasted, respectively than those residing near a health care facility. Ownership of toilet and living close to market were associated with reduced stunting, whereas illness was associated with increased risk of underweight.

CONCLUSIONS

The high prevalence of stunting among pastoral children is a serious public health concern and calls for urgent action. Association of nutritional status of children with dietary intake, and health status, access to health services and toilet availability underlines the need for improved nutrition practices, health care facilities and sanitary conditions in the study area.

Worldwide evidence about infant stunting from a public health perspective: A systematic review

Introduction:

According to the World Health Organization (WHO) global estimates for 2017, 9.6% of children under 5 years old are stunted. Worldwide evidence shows that actions for preventing stunting and catching-up growth are relevant if addressed by all the sectors involved. Therefore, there is a need to identify 'intersectoral actions' to address the risk of stunting during pregnancy and the first 2 years of life.

Objective:

To identify and describe worldwide evidence for prevention, nutritional interventions, and 'intersectoral collaboration' efforts against stunting in infants.

Materials and methods:

We conducted a systematic review in 2019 (PROSPERO CRD42019134431). The search included PubMed, OVID, and Web of Science, as well as WHO and the Food and Agriculture Organization of the United Nations (FAO) official documents and expert recommendations.

Results:

We selected 231 studies: 86.1% described prevention-related factors, 30.7%, nutritional interventions, and 52.8% intersectoral collaboration efforts; 36.4% of the studies were conducted in multiple regions; 61% of the studies described the importance of interventions during pregnancy, 71.9% from birth up to 6 months old, and 84.8% from 6 months up to 2 years old. The most frequent variables described were antenatal care, nutritional counseling for the mother and the newborn, and counseling on micronutrient supplementation.

Conclusions:

Evidence-based understanding of actions geared towards monitoring the risk of stunting-associated factors from pregnancy up to 2 years old is critical.

Pathway Analysis of Growth Faltering Pattern Based on Height for Age in Children Under Five in Indonesia Based on Indonesian National Health Survey 2013

Growth failure has a severe impact on public health problems. Stunting is a particular growth failure contributing to the child mortality and morbidity of non-communicable diseases in adults. Objective: To analyze the determinants of growth failure patterns in children under five years in Indonesia. The further analysis was taken from 6,020 samples, based on the Indonesian National Health Survey (Riskesdas) 2013 (cross-sectional survey with a multistage cluster sampling method). Inclusion criteria are data that have completed records. The exclusion criteria were data having no outlier in anthropometric measurement. Nutrition status is analyzed using WHO AnthroPlus 2009. Data analysis is taken by path analysis in SPSS 21. The growth curve height for the under five-year children in Indonesia is less than the WHO growth standard. The mean height for age z-score (HAZ) has declined in linear patterns among the first five years of life. The determinant of growth is divided into two age groups. Overall, socioeconomic status has an indirect effect adjusted by both age and gender with r 0.10. In children <36 mo, the nutrition status of the mother has a direct and indirect effect on the birth nutrition status with r 0.17, while low birth weight, breastfeeding status, infectious disease, and immunization are the direct factor to HAZ score. In children aged 37-59 mo, infectious disease is a direct factor. Socioeconomic status, BMI of a mother, breastfeeding status, immunization, and infectious disease are the determinants of growth failure patterns in Indonesia.

Dietary patterns in Mexican preschool children are associated with stunting and overweight

OBJECTIVE

To evaluate the association between dietary patterns, stunting, and overweight among Mexican preschoolers.

METHODS

This study was conducted with anthropometric (weight, height/length), sociodemographic (age, gender, education level of household head, socioeconomic status, country region and area, ethnicity, and beneficiary of social programs), and dietary data (Semiquantitative-food frequency questionnaire) on children aged from 1 to 4 years collected from the Mexican National Health and Nutrition Survey-2012. Dietary patterns were derived by principal components analysis. The association between dietary patterns, stunting, and overweight was assessed by prevalence ratios (PR), estimated by Poisson regression.

RESULTS

In total, 1,112 preschoolers (mean age 3.06 years, SD = 1.08 years; 48.8% females) were included in the study; 11.9% of whom presented stunting, and 6.7% overweight. We identified four dietary patterns: Fruits and Vegetables [F&V], Western [W], Traditional [T], and Milk and Liquids [M&L]. Considering the lowest tertile of each dietary pattern as reference, the prevalence of stunting was 2.04 times higher [95%CI: 1.17–3.56] among children in the highest tertile of the “F&V” pattern. The prevalence of stunting was lower among children in the highest tertile of the “W” pattern [PR = 0.48; 95%CI: 0.27–0.85]. Overweight was negatively associated with the “F&V” dietary pattern [PR = 0.37; 95%CI: 0.16–0.85 for its highest tertile], and children whose consumption was mostly equivalent to the “T” pattern showed higher prevalence of stunting [PR = 1.74; 95%CI: 1.01–3.00].

CONCLUSIONS

The prevalence of stunting and overweight in a nationwide sample of Mexican preschoolers was associated with dietary patterns.

Trends in child growth failure among children under five years of age in Ethiopia: Evidence from the 2000 to 2016 Demographic and Health Surveys

INTRODUCTION

In a majority of low- and middle-income countries (LMICs), levels of child growth failure (CGF) have steadily declined since 2000. However, some countries show a different trend. Despite continued investment from the government of Ethiopia as well as donors, CGF levels are still high in Ethiopia. This study aimed to assess trends in CGF and associated sociodemographic, economic and water, sanitation, and hygiene (WASH) factors from 2000 to 2016 in Ethiopia.

METHODS

Data were taken from four rounds of the Ethiopia Demographic and Health Survey (EDHS). Children aged between 0 to 59 months were included. CGF indicators were categorised based on height-for-age z-score (HAZ) < -2 Standard deviation (SD), weight-for-age z-score (WAZ) < -2 SD and weight-for-height z-score (WHZ) < -2 SD. CGF trends were estimated for predicted probabilities and odds ratios (ORs) between 2000 and 2016.

RESULTS

A total sample size of 31978 for HAZ, 32045 for WAZ and 32246 for WHZ were included in the current study. Stunting decreased from an adjusted odds ratio (AOR) = 0.77 (95% CI: 0.67 to 0.88) in 2005 to an AOR = 0.45 (95% CI: 0.39 to 0.53) in 2016 compared with the year 2000. Compared with data in 2000, underweight decreased from an AOR of 0.70 (95% CI: 0.61 to 0.80) in 2005 to an AOR of 0.43 (95% CI: 0.36 to 0.50) in 2016. Wasting declined from an AOR of 0.91 (95% CI: 0.75 to 1.10) in 2005 to an AOR of 0.76 (95% CI: 0.61 to 0.94) in 2016, compared with data in 2000.

CONCLUSIONS

Between 2000 to 2016, there was a decline in CGF levels albeit the levels are still relatively high compared with the World Health Organization (WHO) cut-off levels for public health concern. Observed rates of change varied across sociodemographic, economic and WASH factors which suggest that interventions tailored towards addressing the imbalances across those factors are required.

Choline and docosahexaenoic acid during the first 1000 days and children's health and development in low- and middle-income countries

Choline and DHA are nutrients that, when provided during the first 1000 days from conception to age 2 years, may have beneficial effects on child neurodevelopment as well as related health factors, including birth outcomes and child growth, morbidity, and inflammation. Because these nutrients are found mainly in animal-source foods, they may be lacking in the diets of pregnant and lactating women and young children in low- and middle-income countries, potentially putting children at risk for suboptimal development and health. Prior reviews of these nutrients have mainly focused on studies from high-income countries. Here, a narrative review is presented of studies describing the pre- and postnatal roles of choline, docosahexaenoic acid, and a combination of the 2 nutrients on child neurodevelopment, birth outcomes, growth, morbidity, and inflammation in low- and middle-income countries. More studies are needed to understand the specific, long-term effects of perinatal choline and docosahexaenoic acid intake in various contexts.

Pooled prevalence and associated factors of chronic undernutrition among under-five children in East Africa: A multilevel analysis

BACKGROUND

Childhood undernutrition is the leading cause of under-five mortality and morbidity in the world particularly in East African countries. Although there are studies on child undernutrition in different East African countries, our search of the literature revealed that there is limited evidence of a pooled analysis of these studies. Therefore, this study aimed to investigate the pooled prevalence and associated factors of chronic undernutrition (i.e. stunting) among under-five children in East Africa.

METHODS

A pooled analysis of the Demographic and Health Surveys (DHSs) in 12 East African countries was conducted. A total weighted sample of 79744 under-five children was included in the study. Mixed-effect logistic regression analysis was used to identify significant factors associated with chronic undernutrition since the DHS data has a hierarchical structure. The intra-class correlation coefficient (ICC), Median Odds Ratio (MOR), Likelihood Ratio (LR)-test, and deviance was used for model comparison. Variables with p-value <0.2 in the bivariable mixed-effect logistic regression analysis were considered for the multivariable analysis. In the multivariable multilevel analysis model, the Adjusted Odds Ratio (AOR) with the 95% Confidence Interval (CI) were reported for significant factors.

RESULTS

The pooled prevalence of chronic undernutrition among underfive children in East Africa was 33.3% (95% CI: 32.9%, 35.6%) ranging from 21.9% in Kenya to 53% in Burundi. Children whose mothers lived in rural area (AOR = 1.11, 95% CI: 1.06, 1.16), born to mother who had no formal education (AOR = 1.42, 95% CI: 1.34, 1.50) and primary education (AOR = 1.37, 95% CI: 1.31, 1.44), being in poor household (AOR = 1.66, 95% CI: 1.58, 1.74), and middle household (AOR = 1.42, 95% CI: 1.35, 1.49), child aged 36-48 months (AOR = 1.09, 95% CI: 1.04, 1.14), being male (AOR = 1.19, 95% CI: 1.15, 1.23), 2nd - 4th birth order (AOR = 1.08, 95% CI: 1.03, 1.13), and above 4th 1.27 (AOR = 1.27, 95% CI: 1.19, 1.35), home delivery 1.09 (AOR = 1.09, 95% CI: 1.05, 1.13), small size at birth (AOR = 1.35, 95% CI: 1.29, 1.40) and being multiple births (AOR = 1.98, 95% CI: 1.81, 2.17) were associated with increased odds of stunting. While, antenatal care visit (AOR = 0.89, 95% CI: 0.86, 0.93), mothers aged 25-34 (AOR = 0.83, 95% CI: 0.79, 0.86) and ≥ 35 years (AOR = 0.76, 95% CI: 0.72, 0.81), large size at birth (AOR = 0.85, 95% CI: 0.81, 0.88), and family size >8 (AOR = 0.92, 95% CI: 0.87, 0.98) were associated with decreased odds of stunting.

CONCLUSION

The study revealed that stunting among under-five children remains a major public health problem in East Africa. Therefore, to improve child nutrition status the governmental and non-governmental organizations should design public health interventions targeting rural residents, and the poorest households. Furthermore, enhancing health facility delivery, ANC visit, and maternal health education is vital for reducing child chronic undernutrition.

Factors Associated with Stunting among Children under 5 Years in Five South Asian Countries (2014-2018): Analysis of Demographic Health Surveys

South Asia continues to be the global hub for child undernutrition with 35% of children still stunted in 2017. This paper aimed to identify factors associated with stunting among children aged 0-23 months, 24-59 months, and 0-59 months in South Asia. A weighted sample of 564,518 children aged 0-59 months from the most recent Demographic and Health Surveys (2014-2018) was combined of five countries in South Asia. Multiple logistic regression analyses that adjusted for clustering and sampling weights were used to examine associated factors. The common factors associated with stunting in three age groups were mothers with no schooling ([adjusted odds ratio (AOR) for 0-23 months = 1.65; 95% CI: (1.29, 2.13)]; [AOR for 24-59 months = AOR = 1.46; 95% CI: (1.27, 1. 69)] and [AOR for 0-59 months = AOR = 1.59; 95% CI: (1.34, 1. 88)]) and maternal short stature (height < 150 cm) ([AOR for 0-23 months = 2.00; 95% CI: (1.51, 2.65)]; [AOR for 24-59 months = 3.63; 95% CI: (2.87, 4.60)] and [AOR for 0-59 months = 2.87; 95% CI: (2.37, 3.48)]). Study findings suggest the need for a balanced and integrated nutrition strategy that incorporates nutrition-specific and nutrition-sensitive interventions with an increased focus on interventions for children aged 24-59 months.

COVID-19’s Shadow on Undernourished Children (6–23 months): An Evidence-Based Study on Magnitude and its Determinants in Rajasthan

The prevalence of child undernutrition in India is among the highest in the world, nearly double that of Sub-Saharan Africa, with dire consequences for morbidity, mortality, productivity and economic growth (HNP, World Bank). India is home to most malnourished people in the world (FAO, 2015). According to data tabled in the state assembly, 37% of children below 5 years of age are underweight in the state of Rajasthan. A total of 39% of children in Rajasthan under the age of 5 years are stunted, or too short for their age, which shows that they have been undernourished for quite a while (National Family Health Survey-4—Rajasthan factsheet). Region specific magnitude of under nutrition in young children (6–23 months) at the block level is scarce. The present study carried out by IIHMR University, supported by IPE Global could be of use to the Government, policy makers as well as to the development partners working towards the enhanced nutritional status of the children. The specific objectives of the study were to collect demographic and background information about enrolled children (6–23 months) and to assess the anthropometry based nutritional status as far as wasting, stunting and underweight for the children 6–23 months and its determinants. A cross-sectional survey was undertaken. Three stage sampling method was adopted. Three districts were randomly selected from total districts of Rajasthan and from each selected district, four rural blocks/urban slums based on systematic random sampling were enrolled for the study in Stage 1. For Stage 2, for each selected block 10 villages/urban slums primary sampling unit (PSU) were selected. In the third stage, from each PSU six children in the age group of 6–11 months and 12 children from the age group of 12–23 months based on systematic random sampling were enrolled for the study. It was done from the list available to Accredited Social Health Activist (ASHA)/Anganwadi workers in the respective PSU. Thus, from every district, a sample of 720 respondents comprising two groups of infants was enrolled in the study. Hence, the total sample size for the study was 2,160 for all three selected districts. Socio-demographic and economic indicators of the respondent’s household: Information on the family composition of the household, including age, religion, caste, occupation, income was elicited through pretested semi-structured questionnaire. Anthropometric measurements were taken adopting the standard procedure for the same. WHO Anthro form 3.2.2 programming was utilised for the anthropometric examination to evaluate the magnitude of wasting, stunting and underweight in the enrolled children. A total 92% of the households in the sampled population were the followers of Hinduism. Regarding caste/tribe, around 11% of the households belonged to general category, 16% of the scheduled caste group, while the remaining 28% households were found to be from the scheduled tribe group. The overall pervasiveness of wasting, stunting and underweight was 16.9%, 58.1% and 34.2%, respectively. In case of severe wasting, stunting and underweight among children, it was 6.4%, 36.7% and 12.9% individually. It was revealed that prevalence of undernutrition was higher in males as compared to females in all the three districts. In Rajasthan, existing nutritional status of children, including wasting, stunting and underweight is a cause of concern which may get aggravated due to the current pandemic of COVID-19. Some studied shows that ‘poorer households are much more likely to report much less income during April than richer households compare to income during January and February’. To protect the vulnerable groups, especially women and children, from the effects of this nutritional crisis, there is an urgent need for high-frequency surveillance of vulnerable populations and inter sectoral convergence across segments, including health, agriculture, education, water and sanitation, social protection, commerce and livelihood.

Determinants of stunting among children under 2 years in urban informal settlements in Mumbai, India: evidence from a household census

BACKGROUND

There is limited evidence on the determinants of childhood stunting across urban India or specifically in slum settlements. This study aims to assess the extent of stunting among children under 2 years of age and examine its determinants in informal settlements of Mumbai.

METHODS

Data were collected in 2014-2015 in a post intervention census of a cluster randomized controlled trial to improve the health of women and children. Census covered 40 slum settlements of around 600 households each. A total of 3578 children were included in the study. Mixed effects logistic regression models were used to identify factors associated with stunting.

RESULTS

The prevalence of stunting among children aged 0-23 months was 38%. In the adjusted model, higher maternal education (AOR 0.59; 95% CI 0.42, 0.82), birth interval of at least 2 years (AOR 0.71; 95% CI 0.58, 0.87) and intended conception of the child (AOR 0.80; 95% CI 0.64, 0.99) were associated with lower odds of stunting. Maternal exposure to physical violence (AOR 1.83; 95% CI 1.21, 2.77) was associated with higher odds of being stunted. A child aged 18-23 months had 5.04 times greater odds (95% CI 3.91, 6.5) of being stunted than a child less than 6 months of age. Male child had higher odds of being stunted (AOR 1.33; 95% CI 1.14, 1.54).

CONCLUSIONS

Our findings support a multidimensional aetiology for stunting. The results of the study emphasize the importance of women's status and decision-making power in urban India, along with access to and uptake of family planning and services to provide support for survivors of domestic violence. Ultimately, a multilateral effort is needed to ensure the success of nutrition-specific interventions by focusing on the underlying health and social status of women living in urban slums.

TRIAL REGISTRATION

ISRCTN Register: ISRCTN56183183 , and Clinical Trials Registry of India: CTRI/2012/09/003004.

Milk consumption and childhood anthropometric failure in India: Analysis of a national survey

Dairy milk has been shown to contribute to child growth in many countries, but the relationship between milk intake and anthropometric outcomes among Indian children has not been studied. The objectives were to describe children aged 6–59 months who consume dairy milk in India and determine if dairy milk consumption was associated with lower odds of stunting, underweight and anthropometric failure among Indian children. This was a cross‐sectional study based on the fourth Indian National Family Health Survey (NFHS‐4), which was a national survey conducted between 2015 and 2016 by the Ministry of Health and Family Welfare. The primary exposure was the consumption of dairy milk within the past day or night. The primary outcomes were stunting (height‐for‐age z score < −2), underweight (weight‐for‐age z score < −2) and the composite index of anthropometric failure (CIAF), which is a combination of weight‐for‐age, weight‐for‐height and height‐for‐age. Multivariable logistic regression models and coarsened exact matching (CEM) were used to determine the relationship between dairy milk and odds ratios of each outcome. Setting was in India. Participants were children (N = 107,639) aged 6–59 months. Children who consumed dairy milk in the past day or night had an odds ratio of 0.95 for underweight (95% CI 0.92–0.98, P = .0005), 0.93 for stunting (95% CI 0.90–0.96, P < .0001) and 0.96 for CIAF (95% CI 0.93–0.99, P = .004), compared with children who did not consume dairy milk after adjusting for relevant covariates. When CEM was used among a subset (n = 28,207), evidence for relationships between dairy milk and anthropometric outcomes was consistent but slightly weaker. Widespread, equitable access to dairy milk among childhood may be part of an effort to lower the risk of anthropometric failure among children in India.

Association between Infant and Young Child Feeding (IYCF) Indicators and the Nutritional Status of Children (6-23 Months) in Northern Ghana

Although recommended infant and young child feeding (IYCF) practices have been found to be protective against undernutrition in some settings, there is no finality yet due to inconsistencies in the literature. A cross-sectional survey of 581 mother-child pairs was conducted in northern Ghana in June 2018. The association between IYCF indicators and child undernutrition (stunting and wasting) were assessed. The descriptive analysis showed that 66.4% of the children (6-23 months) were introduced to complementary feeding in a timely manner, 69.4% met the minimum meal frequency, and 38.9% met the minimum acceptable diet daily. The prevalence of stunting, wasting, underweight and overweight was 33.2%, 14.1%, 27% and 2.6%, respectively. From the multivariable binary logistic regression, child gender, child age group and source of power for lighting the household were significantly associated with wasting. Intake of iron-rich foods, child age group, and maternal height were significantly associated with stunting after adjusting for confounders. The prevalence of the compliance with IYCF indicators was relatively high. None of the individual IYCF indicators showed significant association with undernutrition, except intake of iron-rich foods for stunting. Nutrition-specific interventions targeted at improving IYCF practices, dietary diversification and intake of nutrient-rich meals, should be adopted and scaled up to address undernutrition in northern Ghana.

Proximal and contextual correlates of childhood stunting in India: A geo-spatial analysis

BACKGROUND

Globally, India is home to every third child affected by stunting. While numerous studies have examined the correlates of childhood stunting (CS) in India, most of these studies have focused on examining the role of proximal factors, and the role of contextual factors is much less studied. This study presents a comprehensive picture of both proximal and contextual determinants of CS in India, expanding the current evidence base. The present study is guided by the WHO conceptual framework, which outlines the context, causes, and consequences of CS.

DATA AND METHODS

The study used exploratory spatial data analysis tools to analyse the spatial pattern and correlates of CS, using data from the fourth round (2015-16) of the National Family Health Survey (NFHS-4) and the 2011 Census of India.

RESULTS

The study findings reiterate that CS continues to be high in India, with several hot spot states and districts, and that children from the central and eastern region of the nation, namely, Bihar, Jharkhand, Madhya Pradesh, and Uttar Pradesh are particularly vulnerable. Our analysis has identified six risk factors-maternal short stature, large household size, closely spaced births, prevalence of hypertension among women, household poverty, open defecation, and extreme temperature-and four protective factors-female education, access to improved drinking water, dietary diversity among children, and iron and folic acid (IFA) supplementation during pregnancy.

CONCLUSIONS

The study highlights the need for investing in pre-conception care, addressing both demand- and supply-side barriers to increase the coverage of nutrition-specific interventions, implementing programmes to promote the intake of healthy foods from an early age, providing contraceptive counselling and services to unmarried and married adolescents and young women and men, and universalizing quality primary and secondary education that is inclusive and equitable to avert the burden of childhood stunting in India.

Association does not imply prediction: the accuracy of birthweight in predicting child mortality and anthropometric failure

PURPOSE

Epidemiologic studies often conflate the strength of association with predictive accuracy and build classification models based on arbitrarily selected probability cutoffs without considering the cost of misclassification. We illustrated these common pitfalls by building association, prediction, and classification models using birthweight as an exposure and child mortality and child anthropometric failure as outcomes.

METHODS

Nationally representative samples of 188,819 and 164,113 children aged less than 5 years across India were used for our analysis of mortality and anthropometric failure, respectively. We assessed outcomes of neonatal, postneonatal, and child mortality as well as stunting, wasting, and underweight. Birthweight was the main exposure. We used adjusted and unadjusted logistic regression models to evaluate association strength, univariable and multivariable logistic regression models trained on 80% of the data using 10-fold cross-validation to evaluate predictive power, and classification models across a series of possible misclassification cost scenarios to evaluate classification accuracy.

RESULTS

Birthweight was strongly associated with five of six outcomes (P < .001), and associations were robust to covariate adjustment. Prediction models evaluated on the test set showed that birthweight was a poor discriminator of all outcomes (area under the curve < 0.62), and that adding birthweight to a multivariable model did not meaningfully improve discrimination. Prediction models for anthropometric failure showed substantially better calibration than prediction models for mortality. Depending on the ratio of false positive (FP) cost to false negative (FN) cost, the probability cutoff that minimized total misclassification cost ranged from 0.116 (cost ratio = 7:93) to 0.706 (cost ratio = 4:1), TPR ranged from 0.999 to 0.004, and PPV ranged from 0.355 to 0.867..

CONCLUSIONS

Although birthweight is strongly associated with mortality and anthropometric failure, it is a poor predictor of child health outcomes, highlighting that strong associations do not imply predictive power. We recommend that (1) future research focus on building predictive models for anthropometric failure given their clinical relevance in diagnosing individual cases, and that (2) studies that build classifiers report performance metrics across a range of cutoffs to account for variation in the cost of FPs and FNs.

Growth status of children and adolescents born small for gestational age at full term in Korea: data from the KNHANES-V

Objectives Small for gestational age (SGA) status is known to show stunted growth and results in short stature in adults. The aim of this study was to describe the current short stature in subjects born SGA in Korea and to assess catch-up growth (CUG) or non-CUG. Methods We analyzed data from 3,524 subjects (1,831 male) aged 1-18 years who were born as full-term singletons and who participated in the Fifth Korean National Health and Nutrition Examination Survey (2010-2011). Results The prevalence of SGA was 13.4% (n=471). Subjects born SGA had fathers with shorter height, shorter mother's height, and mid-parental height than non-SGA subjects (p<0.05 for all). The odds ratios (ORs) for SGA birth of a short statured father and a short statured mother were 2.00 (95% CI; 1.15-3.47) and 2.11 (95% CI; 1.30-3.40), respectively. Among 471 SGA subjects, 28 subjects (5.9%) were non-CUG, which made up 36.4% of all subjects with short stature. The CUG subjects had a higher father's height, mother's height, mid-parental height, and current BMI (p<0.05 for all). The non-CUG subjects had a higher percentage of fathers being near-short stature (height<10th percentile; 33.3 vs. 12.7%; p=0.008) and mothers being near-short stature (39.3 vs. 13.9%; p<0.001). Conclusion Korean subjects born SGA had a higher risk of current short stature. This population-based nationwide survey also showed that both father's and mother's short stature are risk factors of not only SGA birth but also non-CUG in their children.

Mapping of variations in child stunting, wasting and underweight within the states of India: the Global Burden of Disease Study 2000-2017

BACKGROUND

To inform actions at the district level under the National Nutrition Mission (NNM), we assessed the prevalence trends of child growth failure (CGF) indicators for all districts in India and inequality between districts within the states.

METHODS

We assessed the trends of CGF indicators (stunting, wasting and underweight) from 2000 to 2017 across the districts of India, aggregated from 5 × 5 km grid estimates, using all accessible data from various surveys with subnational geographical information. The states were categorised into three groups using their Socio-demographic Index (SDI) levels calculated as part of the Global Burden of Disease Study based on per capita income, mean education and fertility rate in women younger than 25 years. Inequality between districts within the states was assessed using coefficient of variation (CV). We projected the prevalence of CGF indicators for the districts up to 2030 based on the trends from 2000 to 2017 to compare with the NNM 2022 targets for stunting and underweight, and the WHO/UNICEF 2030 targets for stunting and wasting. We assessed Pearson correlation coefficient between two major national surveys for district-level estimates of CGF indicators in the states.

FINDINGS

The prevalence of stunting ranged 3.8-fold from 16.4% (95% UI 15.2-17.8) to 62.8% (95% UI 61.5-64.0) among the 723 districts of India in 2017, wasting ranged 5.4-fold from 5.5% (95% UI 5.1-6.1) to 30.0% (95% UI 28.2-31.8), and underweight ranged 4.6-fold from 11.0% (95% UI 10.5-11.9) to 51.0% (95% UI 49.9-52.1). 36.1% of the districts in India had stunting prevalence 40% or more, with 67.0% districts in the low SDI states group and only 1.1% districts in the high SDI states with this level of stunting. The prevalence of stunting declined significantly from 2010 to 2017 in 98.5% of the districts with a maximum decline of 41.2% (95% UI 40.3-42.5), wasting in 61.3% with a maximum decline of 44.0% (95% UI 42.3-46.7), and underweight in 95.0% with a maximum decline of 53.9% (95% UI 52.8-55.4). The CV varied 7.4-fold for stunting, 12.2-fold for wasting, and 8.6-fold for underweight between the states in 2017; the CV increased for stunting in 28 out of 31 states, for wasting in 16 states, and for underweight in 20 states from 2000 to 2017. In order to reach the NNM 2022 targets for stunting and underweight individually, 82.6% and 98.5% of the districts in India would need a rate of improvement higher than they had up to 2017, respectively. To achieve the WHO/UNICEF 2030 target for wasting, all districts in India would need a rate of improvement higher than they had up to 2017. The correlation between the two national surveys for district-level estimates was poor, with Pearson correlation coefficient of 0.7 only in Odisha and four small north-eastern states out of the 27 states covered by these surveys.

INTERPRETATION

CGF indicators have improved in India, but there are substantial variations between the districts in their magnitude and rate of decline, and the inequality between districts has increased in a large proportion of the states. The poor correlation between the national surveys for CGF estimates highlights the need to standardise collection of anthropometric data in India. The district-level trends in this report provide a useful reference for targeting the efforts under NNM to reduce CGF across India and meet the Indian and global targets.

Current Status of Malnutrition and Stunting in Pakistani Children: What Needs to Be Done?

Malnutrition is one of the greatest health challenges that affects about 2 billion people globally. Multiple factors including poverty, food insecurity, maternal health and nutritional status, mother's age at marriage and educational status, low birthweight or small for gestational age (SGA), premature births, suboptimal breastfeeding practices, unhealthy dietary and lifestyle patterns, health and immunization status of children, socioeconomic status of family, environmental and household conditions, together with cultural practices and myths, play vital role in affecting the growth of children at early age. Although child stunting has declined in Pakistan, the reduction rate is only 0.5%, which is very low. This may be due to ineffective or inappropriate intervention programs as they are mostly addressing only one issue at a time and don't use the multi-sector approach to address numerous determinants of stunting. It is therefore important to initiate cost-effective multi-tiered intervention approaches to be implemented at pre-conception, pregnancy and early postpartum stages to prevent the problems of malnutrition and stunting in Pakistani children. This review discusses the etiology of child malnutrition and stunting in Pakistan, role of various determinants of stunting and what type of intervention strategies and approaches should be developed and implemented to deal with these problems. Key teaching pointsMalnutrition is one of the greatest global health challenges.Poverty, food insecurity, socioeconomic status, unhealthy dietary patterns, maternal health and nutritional status, low birthweight, suboptimal breast feeding, environmental conditions, cultural practices and myths, are the main factors for child malnutrition and stunting in Pakistan.The slow reduction rate in child stunting may be due to inappropriate intervention programs.Cost-effective multi-tiered intervention approaches must be implemented at pre-conception, pregnancy and early postpartum stages to prevent child malnutrition and stunting in Pakistan.A holistic approach comprising nutrition and WASH interventions, together with strategies to improve the socioeconomic status be developed and implemented to resolve this dilemma.

Water, sanitation and hygiene practices associated with improved height-for-age, weight-for-height and weight-for-age z-scores among under-five children in Nepal

BACKGROUND

Evidence of the influence of water, sanitation and hygiene (WASH) behaviors on childhood nutritional status is inconsistent. Few studies have examined their interactive effects. This study aimed to examine associations and interactions between WASH variables and preschool child undernutrition.

METHODS

Data from a nationally representative sample of 2352 children assessed during the 2016 Nepal Demographic and Health Survey were analyzed by multi-variable linear regression to understand the association between height-for-age (HAZ), weight-for-height (WHZ) and weight-for-age (WAZ) z-scores and WASH variables. Interactions between WASH variables, sex and area of residence on childhood nutritional status were also examined.

RESULTS

The mean z-score [standard deviation] for children's WAZ, HAZ and WHZ scores were - 1.33 [1.1], - 1.52 [1.3] and - 0.65 [1.1], respectively. A unit increase in cluster sanitation coverage was associated with an increase of 0.30 (95%CI: 0.12 to 0.48) for WAZ and 0.28 (95%CI: 0.001 to 0.56) for HAZ scores. Household water purification practice was associated with an increase of 0.24 (95%CI: 0.07 to 0.41) in WHZ score. Handwashing practice with water and soap was associated with an increase of 0.15 (95%CI: 0.04 to 0.25) in WAZ and 0.13 (95%CI: 0.01 to 0.24) in WHZ scores. The effect of water purification practice was higher for rural areas compared to urban settings for HAZ scores (p-value for interaction = 0.02).

CONCLUSIONS

Consistent with findings from other countries in the South Asian region, findings of this study highlight the potential importance of good WASH practices, and therefore the potential of WASH interventions, to contribute to improved nutritional status in rural Nepal.

Y, Westcott JE, Thorsten VR, Sridhar A, Das A, McClure E, Derman RJ, Goldenberg RL, Koso-Thomas M, Goudar SS, Krebs NF. Preconception nutrition intervention improved birth length and reduced stunting and wasting in newborns in South Asia: The Women First Randomized Controlled Trial

South Asia has >50% of the global burden of low birth weight (LBW). The objective was to determine the extent to which maternal nutrition interventions commenced before conception or in the 1st trimester improved fetal growth in this region. This was a secondary analysis of combined newborn anthropometric data for the South Asian sites (India and Pakistan) in the Women First Preconception Maternal Nutrition Trial. Participants were 972 newborn of mothers who were poor, rural, unselected on basis of nutritional status, and had been randomized to receive a daily lipid-based micronutrient supplement commencing ≥3 months prior to conception (Arm 1), in the 1st trimester (Arm 2), or not at all (Arm 3). An additional protein-energy supplement was provided if BMI <20 kg/m2 or gestational weight gain was less than guidelines. Gestational age was established in the 1st trimester and newborn anthropometry obtained <48-hours post-delivery. Mean differences at birth between Arm 1 vs. 3 were length +5.3mm and weight +89g. Effect sizes (ES) and relative risks (RR) with 95% CI for Arm 1 vs. 3 were: length-for-age Z-score (LAZ) +0.29 (0.11-0.46, p = 0.0011); weight-for-age Z-score (WAZ) +0.22 (0.07-0.37, p = 0.0043); weight-to-length-ratio-for-age Z-score (WLRAZ) +0.27 (0.06-0.48, p = 0.0133); LAZ<-2, 0.56 (0.38-0.82, p = 0.0032); WAZ <-2, 0.68 (0.53-0.88, p = 0.0028); WLRAZ <-2, 0.76 (0.64-0.89, p = 0.0011); small-for-gestational-age (SGA), 0.74 (0.66-0.83, p<0.0001); low birth weight 0.81 (0.66-1.00, p = 0.0461). For Arm 2 vs. 3, LAZ, 0.21 (0.04-0.38); WAZ <-2, 0.70 (0.53-0.92); and SGA, 0.88 (0.79-0.97) were only marginally different. ES or RR did not differ for preterm birth for either Arm 1 vs. 3 or 2 vs. 3. In conclusion, point estimates for both continuous and binary anthropometric outcomes were consistently more favorable when maternal nutrition supplements were commenced ≥3 months prior to conception indicating benefits to fetal growth of improving women's nutrition in this population.

Stunting: an overlooked problem in Myanmar – an economic evaluation

Objectives

Stunting increases a child's susceptibility to diseases, increases mortality, and is associated over long term with reduced cognitive abilities, educational achievement, and productivity. We aimed to assess the most effective public health nutritional intervention to reduce stunting in Myanmar.

Methods

We searched the literature and developed a conceptual framework for interventions known to reduce stunting. We focused on the highest impact and most feasible interventions to reduce stunting in Myanmar, described policies to implement them, and compared their costs and projected effect on stunting using data-based decision trees. We estimated costs from the government perspective and calculated total projected cases of stunting prevented and cost per case prevented (cost-effectiveness). All interventions were compared to projected cases of stunting resulting from the current situation (e.g., no additional interventions).

Results

Three new policy options were identified. Operational feasibility for all three options ranged from medium to high. Compared to the current situation, two were similarly cost-effective, at an additional USD 598 and USD 667 per case of stunting averted. The third option was much less cost-effective, at an additional USD 27,741 per case averted. However, if donor agencies were to expand their support in option three to the entire country, the prevalence of 22.5 percent would be reached by 2025 at an additional USD 667 per case averted.

Conclusions

A policy option involving immediate expansion of the current implementation of proven nutrition-specific interventions is feasible. It would have the highest impact on stunting and would approach the WHO 2025 target.

Infant and young child feeding practices and child linear growth in Nepal: Regression-decomposition analysis of national survey data, 1996-2016

Suboptimal infant and young child feeding (IYCF) practices have profound implications on child survival, health, growth, and development. First, our study analysed trends in 18 IYCF indicators and height‐for‐age z‐score (HAZ) and stunting prevalence across Nepal's Family Health Survey 1996 and four rounds of Nepal Demographic and Health Surveys from 2001–2016. Second, we constructed multivariable regression models and decomposed the contribution of optimal IYCF practices on HAZ and stunting prevalence over the 1996–2016 period. Our findings indicate that most age‐appropriate IYCF practices and child linear growth outcomes improved over the past two decades. At present, according to the World Health Organization's tool for national assessment of IYCF practices, duration of breastfeeding is rated very good, early initiation of breastfeeding and exclusive breastfeeding (EBF) are rated good, whereas minimal bottle‐feeding and introduction of solid, semi‐solid or soft foods are rated fair. Our study also reports that a paucity of age‐appropriate IYCF practices—in particular complementary feeding—are significantly associated with increased HAZ and decreased probability of stunting (p < .05). Moreover, age‐appropriate IYCF practices—in isolation—made modest statistical contributions to the rapid and sustained reduction in age‐specific child linear growth faltering from 1996–2016. Nevertheless, our findings indicate that comprehensive multisectoral nutrition strategies—integrating and advocating optimal IYCF—are critical to further accelerate the progress against child linear growth faltering. Furthermore, specific focus is needed to improve IYCF practices that have shown no significant development over the past two decades in Nepal: EBF, minimum acceptable diet, and minimal bottle‐feeding.

Factors associated with dietary diversity and length-for-age z-score in rural Ethiopian children aged 6-23 months: A novel approach to the analysis of baseline data from the Sustainable Undernutrition Reduction in Ethiopia evaluation

Infants and young children need diets high in nutrient density and diversity to meet the requirements of rapid growth and development. Our aim was to evaluate sociodemographic, agricultural diversity, and women's empowerment factors associated with child dietary diversity and length-for-age z-score (LAZ) in children 6-23 months using data collected as part of the Sustainable Undernutrition Reduction in Ethiopia (SURE) evaluation study baseline survey in May-June 2016. We here present a novel analysis using directed acyclic graphs (DAGs) to represent our assumptions about the causal influences between the factors of interest and the outcomes. The causal diagrams enabled the identification of variables to be included in multivariable analysis to estimate the total effects of factors of interest using ordinal logistic/linear regression models. We found that child dietary diversity was positively associated with LAZ with children consuming 4 or more food groups having on average an LAZ score 0.42 (95% CI [0.08, 0.77]) higher than those consuming no complementary foods. Household production of fruits and vegetables was associated with both increased child dietary diversity (adjusted OR 1.16; 95% CI [1.09, 1.24]) and LAZ (adjusted mean difference 0.05; 95% CI [0.005, 0.10]). Other factors positively associated with child dietary diversity included age in months, socio-economic status, maternal education, women's empowerment and dietary diversity, paternal childcare support, household food security, fruit and vegetable cultivation, and land ownership. LAZ was positively associated with age, socio-economic status, maternal education, fruit and vegetable production, and land ownership.