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deSouza PN, Hammer M, Anthamatten P, Kinney PL, Kim R, Subramanian SV, Bell ML, Mwenda KM. Impact of air pollution on stunting among children in Africa. Environ Health 2022; 21:128. [PMID: 36503479 PMCID: PMC9743768 DOI: 10.1186/s12940-022-00943-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 11/24/2022] [Indexed: 05/31/2023]
Abstract
BACKGROUND Undernutrition is a global public health crisis, causing nearly half of deaths for children under age 5 years. Little is known regarding the impact of air pollution in-utero and early childhood on health outcomes related to undernutrition. The aim of our study is to evaluate the association of prenatal and early-life exposure to PM2.5 and child malnutrition as captured by the height-for-age z-score (HAZ), and stunting in 32 countries in Africa. We also evaluated critical windows of susceptibility during pregnancy to each environmental risk. METHODS We linked nationally representative anthropometric data from 58 Demographic and Health Surveys (DHS) (n = 264,207 children < 5 years of age) with the average in-utero PM2.5 concentrations derived from satellite imagery. We then estimated associations between PM2.5 and stunting and HAZ after controlling for child, mother and household factors, and trends in time and seasonality. RESULTS We observed lower HAZ and increased stunting with higher in-utero PM2.5 exposure, with statistically significant associations observed for stunting (OR: 1.016 (95% CI: 1.002, 1.030), for a 10 μg/m3 increase). The associations observed were robust to various model specifications. Wald tests revealed that sex, wealth quintile and urban/rural were not significant effect modifiers of these associations. When evaluating associations between trimester-specific PM2.5 levels, we observed that associations between PM2.5 and stunting was the largest. CONCLUSIONS This is one of the first studies for the African continent to investigate in-utero and early-life exposure to PM2.5 is an important marker of childhood undernutrition. Our results highlight that PM2.5 concentrations need to be urgently mitigated to help address undernutrition in children on the continent.
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Affiliation(s)
- Priyanka N deSouza
- Department of Urban and Regional Planning, University of Colorado Denver, Denver, CO, USA.
- CU Population Center, University of Colorado Boulder, Boulder, CO, USA.
| | - Melanie Hammer
- Department of Energy, Environmental, and Chemical Engineering, Washington University in St. Louis, St. Louis, MO, 63130, USA
- Department of Physics and Atmospheric Science, Dalhousie University, Halifax, NS, Canada
| | - Peter Anthamatten
- Department of Geography and Environmental Sciences, University of Colorado Denver, Denver, CO, USA
| | | | - Rockli Kim
- Division of Health Policy & Management, College of Health Science, Korea University, 145 Anam-ro, Seongbuk-gu, Seoul, 02841, South Korea
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, 02841, South Korea
- Harvard Center for Population and Development Studies, Bow Street, Cambridge, MA, 02138, USA
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Bow Street, Cambridge, MA, 02138, USA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue, Boston, MA, 02115, USA
| | - Michelle L Bell
- School of the Environment, Yale University, New Haven, CT, USA
| | - Kevin M Mwenda
- Spatial Structures in the Social Sciences, Brown University, Providence, RI, USA
- Population Studies and Training Center, Brown University, Providence, RI, USA
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Gausman J, Kim R, Li Z, Tu L, Rajpal S, Joe W, Subramanian SV. Comparison of Child Undernutrition Anthropometric Indicators Across 56 Low- and Middle-Income Countries. JAMA Netw Open 2022; 5:e221223. [PMID: 35275168 PMCID: PMC8917428 DOI: 10.1001/jamanetworkopen.2022.1223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The United Nations' Sustainable Development Goal Target 2.2 seeks to end all forms of malnutrition by 2030 by meeting targets, including the elimination of stunting and wasting in all children younger than 5 years. Such indicators are used to monitor childhood undernutrition but may not provide a complete picture at a population level. OBJECTIVE To compare global estimates of the prevalence of undernutrition using conventional indicators of anthropometric failure (AF; stunting, underweight, and wasting); the Composite Index of Anthropometric Failure (CIAF); and a proposed classification system called Categories of Anthropometric Failure (CAF) as well as to investigate the association of the conventional indicators, CIAF, and CAF with diarrheal disease as an assessment of the validity of each measure. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of the prevalence of undernutrition among children in 56 low- and middle-income countries using data from the nationally representative Demographic and Health Surveys. The study included 530 906 children younger than 5 years. Data were collected from June 2005 to December 2018 and analyzed from September 27, 2020, to February 4, 2021. MAIN OUTCOMES AND MEASURES Undernutrition identified according to conventional indicators (stunting, underweight, and wasting), the CIAF, and the proposed CAF classification system was estimated and compared. Six logistic regression models were used to examine the association between different classifications of anthropometric failure (AF) and morbidity. RESULTS A total of 530 906 children (mean [SD] age, 29.0 [17.2] months; 272 355 [51.3%] boys and 258 551 [48.7%] girls) from 56 low- and middle-income countries were included in the analysis. Estimates of undernutrition generated using the conventional indicators of stunting, underweight, and wasting were lower than estimates generated using the CIAF in all countries. The CAF classification system pointed to considerable variation across countries in children with multiple AFs, which does not correspond to the overall prevalence of undernutrition. For example, 7.5% of children in Niger and 7.1% of children in Timor-Leste were stunted, underweight, and wasted, while 56.0% of children in Niger and 71.1% of children in Timor-Leste were undernourished according to the CIAF. In addition, children who had stunting, underweight, and wasting had 1.52 (95% CI, 1.45-1.61) times the odds of diarrhea compared with children who exhibited no AFs. CONCLUSIONS AND RELEVANCE The results of this study highlight the importance of using different approaches to aid understanding of the entire spectrum of AF with regard to research and development of policies and programs to address AF. The use of the CIAF and the CAF classification system may be useful for treatment to prevent AFs and could accelerate progress in meeting targets for the Sustainable Development Goal.
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Affiliation(s)
- Jewel Gausman
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Rockli Kim
- Division of Health Policy and Management, College of Health Science, Korea University, Seoul, South Korea
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
| | - Zhihui Li
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Lucia Tu
- Nathan S. Kline Institute for Psychiatric Research, Orangeburg, New York
| | - Sunil Rajpal
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea
- Department of Economics, FLAME University, New Delhi, India
| | - William Joe
- Population Research Centre, Institute of Economic Growth, Delhi University Enclave, North Campus, Delhi, India
| | - S. V. Subramanian
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Jain A, Wang W, James KS, Sarwal R, Kim R, Subramanian SV. Small Area Variations in Dietary Diversity Among Children in India: A Multilevel Analysis of 6–23-Month-Old Children. Front Nutr 2022; 8:791509. [PMID: 35252284 PMCID: PMC8890590 DOI: 10.3389/fnut.2021.791509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/30/2021] [Indexed: 11/17/2022] Open
Abstract
Dietary diversity is an important indicator of child malnutrition. However, little is known about the geographic variation of diet indicators across India, particularly within districts and across states. As such, the purpose of this paper was to elucidate the small area variations in diet indicators between clusters within districts of India. Overall, we found that clusters were the largest source of variation for children not eating grains, roots, and tubers, legumes and nuts, dairy, vitamin A-rich vegetables and fruits, and other vegetables and fruits. We also found positive correlations between the district percent and cluster standard deviations of children not breastfeeding or eating grains, roots, and tubers, but negative correlations between the district percent and cluster standard deviation for the remaining seven outcomes. These findings underscore the importance of targeting clusters to improve child dietary diversity.
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Affiliation(s)
- Anoop Jain
- Global Health and Social Medicine, Harvard Medical School, Boston, MA, United States
| | - Weiyu Wang
- Harvard Center for Population and Development Studies, Cambridge, MA, United States
| | - K. S. James
- International Institute for Population Sciences, Mumbai, India
| | - Rakesh Sarwal
- National Institution for Transforming India (NITI) Aayog, Government of India, New Delhi, India
| | - Rockli Kim
- Division of Health Policy and Management, College of Health Science, Korea University, Seoul, South Korea
- *Correspondence: Rockli Kim
| | - S. V. Subramanian
- Harvard Center for Population and Development Studies, Cambridge, MA, United States
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- S. V. Subramanian
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Petermann-Rocha F, Rao N, Pell JP, Celis-Morales C, Wong ICK, Ho FK, Ip P. Weight-for-Height, Body Fat, and Development in Children in the East Asia and Pacific Region. JAMA Netw Open 2022; 5:e2142458. [PMID: 34989793 PMCID: PMC8739761 DOI: 10.1001/jamanetworkopen.2021.42458] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Weight-for-height z score (WHZ) is a standard indicator of children's nutritional status even though it does not fully reflect body fat. OBJECTIVE To examine the combined association of WHZ and body fat with early development in the East Asia and Pacific region. DESIGN, SETTING, AND PARTICIPANTS Children from the East Asia-Pacific Early Child Development Scales validation study, with full data available regarding their nutritional status and outcomes, were included in this cross-sectional analysis. In brief, a multilevel stratified random sampling was used to select representative samples from each participating country in the study. WHZ and body fat were independently trichotomized using established references and were combined to form a 9-category exposure variable. Data collection was performed between 2012 and 2014, and the analyses were conducted in June 2021. MAIN OUTCOMES AND MEASURES The binary outcome variable of not being developmentally on track (hereafter referred to as poor development) was defined as a score less than the 25th percentile in the following domains: cognitive, language, socioemotional, motor development, and total development score. Poisson regression models were used to analyze the associations between the combined categories and poor development, adjusted for sociodemographic factors. RESULTS A total of 6815 children (mean [SD] age, 4.02 [0.8] years; 3434 girls [50.4%]) had full data available and were included in this study. Compared with children with normal weight and normal fat, those with wasting and low body fat had the highest likelihood of total poor development (prevalence ratio, 1.47; 95% CI, 1.28-1.70), followed by those with normal weight but low fat (prevalence ratio, 1.23; 95% CI, 1.11-1.36). Similar associations were found in language, cognitive, and socioemotional development, but not in motor development. CONCLUSIONS AND RELEVANCE Poor development was more commonly found in children with low body fat independent of WHZ (wasted or normal weight). Early public health strategies may consider using a combination of WHZ and body fat as an indicator of poor development.
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Affiliation(s)
- Fanny Petermann-Rocha
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- Faculty of Medicine, Universidad Diego Portales, Santiago, Chile
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Nirmala Rao
- Faculty of Education, The University of Hong Kong, Hong Kong
| | - Jill P. Pell
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Carlos Celis-Morales
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
- Centre of Exercise Physiology Research, Universidad Mayor, Providencia, Chile
- Laboratorio de Rendimiento Humano, Grupo de Estudio en Educación, Actividad Física y Salud, Universidad Católica del Maule, Talca, Chile
| | - Ian C. K. Wong
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong
- University College London School of Pharmacy, London, United Kingdom
| | - Frederick K. Ho
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Patrick Ip
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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Gausman J, Kim R, Subramanian S. Associations of single versus multiple anthropometric failure with mortality in children under 5 years: A prospective cohort study. SSM Popul Health 2021; 16:100965. [PMID: 34869820 PMCID: PMC8626676 DOI: 10.1016/j.ssmph.2021.100965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 11/10/2021] [Accepted: 11/10/2021] [Indexed: 11/20/2022] Open
Abstract
Background/objectives Stunting, underweight, and wasting are used to monitor nutritional status in children, but they do not identify children with concurrent anthropometric failures (AF). Our study estimates the association between AF and mortality in children with single versus multiple failures, then calculates the percentage of child deaths attributable to AF. Subjects/methods Using data from a prospective, longitudinal study of 3605 children from age 1 to age 5 years in Ethiopia and India, we estimate the association between AF and mortality using conventional definitions (stunting, underweight, and wasting) and the mutually exclusive categories of stunted only underweight only, wasted only, stunted and underweight (SU), underweight and wasted, and stunted, underweight, and wasted (SUW), adjusting for socioeconomic status and other demographic variables. Last, we calculate the population attributable fraction. Results Children who were SU and SUW had 3.20 (95% CI: 1.69, 6.06; p < 0.001) and 5.52 (95% CI: 2.25, 13.56; p < 0.001) times the odds of death in fully adjusted models by Round 2 compared to children with no failure, while no increased mortality risk was found among children with other categories of failure. We estimate that 42.69% of child deaths can be attributed to children who are SUW (17.02%) or SU (25.67%), accounting for nearly 80% of child deaths from AF. Conclusions This study provides new insight to programs and policy to better identify children most at risk of malnutrition-related mortality.
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Affiliation(s)
- Jewel Gausman
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Rockli Kim
- Division of Health Policy and Management, College of Health Sciences, Korea University, Seoul, South Korea
- Department of Public Health Sciences, Graduate School, Korea University, Seoul, South Korea
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
| | - S.V. Subramanian
- Harvard Center for Population and Development Studies, Cambridge, MA, USA
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Corresponding author. Population Health and Geography, Harvard Center for Population & Development Studies, 9 Bow Street, Cambridge, MA, 02138, USA.
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Ho FK, Rao N, Tung KTS, Wong RS, Wong WHS, Tung JYL, Chua GT, Tso WWY, Bacon-Shone J, Wong ICK, Yousafzai A, Wright C, Ip P. Association of Early Nutritional Status With Child Development in the Asia Pacific Region. JAMA Netw Open 2021; 4:e2139543. [PMID: 34913975 PMCID: PMC8678697 DOI: 10.1001/jamanetworkopen.2021.39543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
IMPORTANCE Stunting was used as a proxy for underdevelopment in early childhood in previous studies, but the associations between child development and other growth and body composition parameters were rarely studied. OBJECTIVE To estimate the association between malnutrition and early child development (ECD) at an individual level. DESIGN, SETTING, AND PARTICIPANTS This population-based, cross-sectional study used data from the East Asia Pacific Early Child Development Scales, a population-representative survey of children aged 3 to 5 years old, conducted in 2012 to 2014 in communities in Cambodia, China, Mongolia, Papua New Guinea, and Vanuatu. Data analysis was performed from November 2019 to April 2021. EXPOSURES Stunting (height-for-age [HFA] z score less than -2), wasting (weight-for-height z score less than -2), overweight (weight-for-height z score greater than 2), body mass index (BMI)-for-age z score, and body fat proportion based on existing growth standard and formula. MAIN OUTCOMES AND MEASURES ECD directly assessed using the validated East Asia-Pacific ECD Scales. RESULTS A total of 7108 children (3547 girls; mean [SD], age 4.48 [0.84] years) were included in this study. The prevalence of stunting was 27.1% (range across countries, 1.2%-55.0%), that of wasting was 13.7% (range, 5.4%-35.9%), and that of overweight was 15.9% (range, 2.2%-53.7%). Adjusted for country variations, age, sex, urbanicity, family socioeconomic status, and body fat proportion, ECD was linearly associated with HFA (β, 1.57; 95% CI, 1.35-1.80) and BMI-for-age (β, 0.64; 95% CI, 0.45-0.82). After adjustment for BMI and height, better ECD was associated with low body fat proportion (β, 0.93; 95% CI, 0.45-1.42). The association of HFA was more pronounced in Southeast Asia and the Pacific region than in East Asia, and the association of fat proportion was specific to children living in urban environments. CONCLUSIONS AND RELEVANCE HFA, BMI-for-age, and body fat proportion were independently associated with ECD, and these findings suggest that future studies should consider using these parameters to estimate the prevalence of child underdevelopment; nutritional trials should examine to what extent the associations are causal.
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Affiliation(s)
- Frederick K. Ho
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Nirmala Rao
- Faculty of Education, The University of Hong Kong, Hong Kong
| | - Keith T. S. Tung
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Rosa S. Wong
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Wilfred H. S. Wong
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Joanna Y. L. Tung
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
- Department of Paediatrics, Hong Kong Children’s Hospital, Hong Kong
| | - Gilbert T. Chua
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
| | - Winnie W. Y. Tso
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
- The State Key Laboratory of Brain and Cognitive Sciences, University of Hong Kong, Hong Kong
| | - John Bacon-Shone
- Social Science Research Centre, The University of Hong Kong, Hong Kong
| | - Ian C. K. Wong
- Centre for Safe Medication Practice and Research, The University of Hong Kong, Hong Kong
- UCL School of Pharmacy, University College London, London, United Kingdom
| | - Aisha Yousafzai
- Department of Global Health and Population, Harvard University, Cambridge, Massachusetts
| | - Charlotte Wright
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
- School of Medicine, Dentistry, and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Patrick Ip
- Department of Paediatrics and Adolescent Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong
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Heemann M, Kim R, Vollmer S, Subramanian SV. Assessment of Undernutrition Among Children in 55 Low- and Middle-Income Countries Using Dietary and Anthropometric Measures. JAMA Netw Open 2021; 4:e2120627. [PMID: 34383059 DOI: 10.1001/jamanetworkopen.2021.20627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Evidence on the suitability of anthropometric failure (ie, stunting, underweight, and wasting) as a stand-alone measure of child undernutrition can inform global and national nutrition and health agendas. OBJECTIVE To provide a comprehensive estimate of the prevalence of child undernutrition by evaluating both dietary and anthropometric measures simultaneously across 55 low- and middle-income countries. DESIGN, SETTING, AND PARTICIPANTS This was a cross-sectional study that used Demographic and Health Surveys program data from July 2009 to January 2019, to allocate children into dietary and anthropometric failure categories. Nationally representative household surveys were conducted in 55 low- and middle-income countries. Participants included children aged 6 to 23 months who were born singleton and had valid anthropometric measures as well as available 24-hour food intake recollection. Data analysis was conducted from August 23 to October 22, 2020. EXPOSURES Two factors were considered to allocate children into the respective categories. Dietary failure was based on the World Health Organization standards for minimum dietary diversity. Anthropometric failure was constructed using the World Health Organization child growth reference standard z score for stunted growth, muscle wasting, and less than average weight for age. MAIN OUTCOMES AND MEASURES Dietary and anthropometric failures were cross-tabulated, which yielded 4 potential outcomes: dietary failure only, anthropometric failure only, both failures, and neither failure. Total child populations for each category were extrapolated from United Nations population estimates. RESULTS Of the 162 589 children (median age [range], 14 months [6-23 months]; 83 467 boys [51.3%]; 78 894 Asian children [48.5%]) in our sample, 42.9% of children had dietary failure according to the standard World Health Organization definition without being identified as having anthropometric failures. In all, 34.7% had both failures, 42.9% had dietary failure only, 8.3% had anthropometric failure only, and 14.1% had neither failure. Dietary and anthropometric measures were discordant for 51.2% of children; these children had nutritional needs identified by only 1 of the 2 measures. Dietary failure doubled the proportion of children in need of dietary interventions compared with anthropometry alone (43%). A total of 45.3 million additional children who experienced undernutrition in these 55 countries were not captured through the evaluation of anthropometric failures only. These results were consistent across geographic regions. CONCLUSIONS AND RELEVANCE The results of this cross-sectional study suggest that the current standard of measuring child undernutrition by estimating the prevalence of anthropometric failure should be complemented with dietary and food-based measures. Anthropometry alone may fail to identify many children who have insufficient dietary intake.
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Affiliation(s)
- Markus Heemann
- Department of Development Economics, Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - Rockli Kim
- Division of Health Policy and Management, Korea University College of Health Science, Seoul, South Korea
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, South Korea
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
| | - Sebastian Vollmer
- Department of Development Economics, Centre for Modern Indian Studies, University of Goettingen, Göttingen, Germany
| | - S V Subramanian
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Beckerman-Hsu JP, Chatterjee P, Kim R, Sharma S, Subramanian SV. A typology of dietary and anthropometric measures of nutritional need among children across districts and parliamentary constituencies in India, 2016. J Glob Health 2020; 10:020424. [PMID: 33110583 PMCID: PMC7569191 DOI: 10.7189/jogh.10.020424] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Anthropometry is the most commonly used approach for assessing nutritional need among children. Anthropometry alone, however, cannot differentiate between the two immediate causes of undernutrition: inadequate diet vs disease. We present a typology of nutritional need by simultaneously considering dietary and anthropometric measures, dietary and anthropometric failures (DAF), and assess its distribution among children in India. METHODS We used the 2015-16 National Family Health Survey, a nationally representative sample of children aged 6-23 months (n = 67 247), from India. Dietary failure was operationalized using World Health Organization (WHO) standards for minimum dietary diversity. Anthropometric failure was operationalized using WHO child growth reference standard z-score of <-2 for height-for-age (stunting), weight-for-age (underweight) and weight-for-height (wasting). We also created a combined anthropometric measure for children who had any one of these three anthropometric failures. We cross-tabulated dietary and anthropometric failures to produce four combinations: Dietary Failure Only (DFO), Anthropometric Failure Only (AFO), Both Failures (BF), and Neither Failure (NF). We estimated the prevalence and distribution of the four types, nationally, and across 640 administrative districts and 543 Parliamentary Constituencies (PCs) in India. RESULTS Nationally, 80.3% of children had dietary failure and 53.7% had at least one anthropometric failure. The prevalence for the four DAF types was: 44.0% (BF), 36.3% (DFO), 9.8% (AFO), and 9.9% (NF). Dietary and anthropometric measures were discordant for 46.1% of children; these children had nutritional needs identified by only one of the two measures. Nationally, this translates to 12 181 627 children with DFO and 3 281 913 children with AFO; the nutritional needs of these children would not be captured if using only dietary or anthropometric assessment. Substantial variation was observed across districts and PCs for all DAF types. The interquartile ranges for districts were largest for BF (29.8%-53.0%) and lowest for AFO (5.5%-13.4%). CONCLUSIONS The current emphasis on anthropometry for measuring nutritional need should be complemented with diet- and food-based measures. By differentiating inadequate food intake from other causes of undernutrition, the DAF typology brings precision in identifying nutritional needs among children. These insights may improve the development and targeting of nutrition interventions.
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Affiliation(s)
| | - Pritha Chatterjee
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston Massachusetts, USA
| | - Rockli Kim
- Interdisciplinary Program in Precision Public Health, Department of Public Health Sciences, Graduate School of Korea University, Seoul, Republic of Korea; Department of Public Health Sciences, Graduate School, Korea University, Seoul, South Korea; Harvard Center for Population and Development Studies, Cambridge, Massachusetts, USA
| | | | - S V Subramanian
- Harvard Center for Population and Development Studies, Cambridge, Massachusetts, USA; and Department of Social and Behavioral Sciences, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
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Anjorin SS, Uthman OA, Ameyaw EK, Ahinkorah BO, Chattu VK, Bishwajit G, Seidu AA, Darteh EKM, Yaya S. Undernutrition, polygynous context and family structure: a multilevel analysis of cross-sectional surveys of 350 000 mother-child pairs from 32 countries. BMJ Glob Health 2020; 5:e002637. [PMID: 33060094 PMCID: PMC7566434 DOI: 10.1136/bmjgh-2020-002637] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 08/24/2020] [Accepted: 08/25/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Contextual factors, especially where people live, has been linked to various health outcomes, therefore, there is an increasing focus on its implication for policies and implementation of health interventions. Polygyny is a widespread practice in sub-Saharan Africa that also reflects socioeconomic and sociocultural features. This study investigated the association between polygynous context and risk of undernutrition. METHODS Recent Demographic and Health Surveys involving 350 000 mother-child pairs from 32 sub-Saharan African countries conducted between 2010 and 2018 as of March 2020, were analysed using relevant descriptive and 3-level multilevel logistic regression modelling. Undernutrition among under-5 was defined as underweight, stunting and wasting using the WHO Multicentre Growth Reference Study. Odd Ratio (OR) at 95% credible interval was used to report the associations. RESULTS The prevalence of contextual polygyny varied widely across the 32 sub-Saharan African countries, the lowest (0%) found in one of the regions in South Africa and the highest (52%) in one of the regions in Uganda. Underweight, stunting and wasting were lowest in Uganda (3.5%, 9.3%-1.27%, respectively), stunting was highest in Mozambique (37.1%) while wasting was highest in Niger (7.7%). Furthermore, the results showed that the contextual prevalence of polygynous practice exacerbates the risk of underweight (1.003 (0.997-1.008)) and wasting (1.014 (1.007-1.021)) among under-5 children, even when gender inequality and sociodemographic indicators were adjusted for. Polygyny was negatively associated with stunting though not significant; multiple births had the strongest and positive association with the risk of undernutrition among under-5 children in sub-Saharan Africa. CONCLUSIONS This study further corroborates the strong influence of contextual factors on health outcomes-which is undernutrition in this study. In addition to specific interventions aimed at reducing the prevalence of undernutrition, broader strategies that will address contextual issues are required.
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Affiliation(s)
- Seun Stephen Anjorin
- Warwick Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Olalekan A Uthman
- Warwick Centre for Applied Health Research and Delivery (WCAHRD), Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, West Midlands, UK
| | - Edward Kwabena Ameyaw
- School of Public Health, Faculty of Health, University of Technology Sydney, Australia, University of Technology, Sydney, New South Wales, Australia
| | - Bright Opoku Ahinkorah
- School of Public Health, Faculty of Health, University of Technology Sydney, Australia, University of Technology, Sydney, New South Wales, Australia
| | - Vijay Kumar Chattu
- Division of Occupational Medicine, Department of Medicine, University of Toronto, ON Canada, University of Toronto, Toronto, Ontario, Canada
| | - Ghose Bishwajit
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada, University of Ottawa, Ottawa, Ontario, Canada
| | - Abdul-Aziz Seidu
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana, University of Cape Coast, Cape Coast, Central, Ghana
| | - Eugene Kofuor Maafo Darteh
- Department of Population and Health, University of Cape Coast, Cape Coast, Ghana, University of Cape Coast, Cape Coast, Central, Ghana
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Ontario, Canada, University of Ottawa, Ottawa, Ontario, Canada
- The George Institute for Global Health, Imperial College London, London, Ontario, UK
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10
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Rodgers J, Kim R, Subramanian SV. Explaining Within- vs Between-Population Variation in Child Anthropometry and Hemoglobin Measures in India: A Multilevel Analysis of the National Family Health Survey 2015-2016. J Epidemiol 2019; 30:485-496. [PMID: 31611523 PMCID: PMC7557174 DOI: 10.2188/jea.je20190064] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background The complex etiology of child growth failure and anemia—commonly used indicators of child undernutrition—involving proximate and distal risk factors at multiple levels is generally recognized. However, their independent and joint effects are often assessed with no clear conceptualization of inferential targets. Methods We utilized hierarchical linear modeling and a nationally representative sample of 139,116 children aged 6–59 months from India (2015–2016) to estimate the extent to which a comprehensive set of 27 covariates explained the within- and between-population variation in height-for-age, weight-for-age, weight-for-height, and hemoglobin level. Results Most of the variation in child anthropometry and hemoglobin measures was attributable to within-population differences (80–85%), whereas between-population differences (including communities, districts, and states) accounted for only 15–20%. The proximate and distal covariates explained 0.2–7.5% of within-population variation and 2.1–34.0% of between-population variation, depending on the indicator of interest. Substantial heterogeneity was observed in the magnitude of within-population variation, and the fraction explained, in child anthropometry and hemoglobin measures across the 36 states/union territories of India. Conclusions Policies and interventions aimed at reducing between-population inequalities in child undernutrition may require a different set of components than those concerned with within-population inequalities. Both are needed to promote the health of the general population, as well as that of high-risk children.
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Affiliation(s)
| | - Rockli Kim
- Harvard Center for Population & Development Studies.,Division of Health Policy and Management, College of Health Sciences, Korea University.,Department of Public Health Sciences, Graduate School, Korea University
| | - S V Subramanian
- Harvard Center for Population & Development Studies.,Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health
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11
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Nujić D, Karšić M, Milas V, Pavlović N, Holik D, Milas J. Body mass index trend as a new parameter for evaluating children's nutritional status. Public Health 2019; 173:138-145. [DOI: 10.1016/j.puhe.2019.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Revised: 03/02/2019] [Accepted: 04/25/2019] [Indexed: 01/13/2023]
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12
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Joe W, Rajpal S, Kim R, Laxmaiah A, Harikumar R, Arlappa N, Meshram I, Balakrishna N, Radhika M, Swaminathan S, Subramanian SV. Association between anthropometric-based and food-based nutritional failure among children in India, 2015. MATERNAL AND CHILD NUTRITION 2019; 15:e12830. [PMID: 30989801 DOI: 10.1111/mcn.12830] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 03/27/2019] [Accepted: 04/04/2019] [Indexed: 01/23/2023]
Abstract
Inadequate dietary intake is a critical underlying determinant of child undernutrition. This study examined the association between anthropometric-based and food-based nutritional failure among children in India. We used the 2015-2016 National Nutrition Monitoring Bureau data where anthropometric outcomes and food intake were both measured for each child. We followed the World Health Organization child growth reference standards to define anthropometric failures (i.e., height-for-age z score < -2 SD for stunting, weight-for-age z score < -2 SD for underweight, and weight-for-height z score < -2 SD for wasting), and the Indian Council of Medical Research recommended dietary allowance (RDA) to define adequacy in intake of calorie, protein, and fat. We used descriptive and regression-based assessments to test the association between the two indicators of nutritional failure and also computed the area under the receiver operating characteristic curve (AUC). The prevalence of stunting, underweight, and wasting was 28.6%, 24.3%, and 12.8%, respectively, whereas 78.2%, 27.4%, and 50.8% of the children had below RDA norms consumption of calorie, protein, and fat, respectively. We found weak-to-null correlation between anthropometric failures and food failures (Pearson correlation ranging from -0.013 to 0.147) and poor discriminatory accuracy (AUC < 0.62), suggesting that in the Indian context, anthropometric failures are not directly associated with food intake. This finding highlights the need for improving adequate intake of macronutrients and draws attention toward adopting a multifactorial approach to improve child nutrition in India. Poor food intake itself merits exclusive policy focus as it is an important nutrition and health concern.
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Affiliation(s)
- William Joe
- Population Research Centre, Institute of Economic Growth, New Delhi, India
| | - Sunil Rajpal
- ICSSR Doctoral Fellow, Institute of Economic Growth, New Delhi, India
| | - Rockli Kim
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Avula Laxmaiah
- Division of Community studies, ICMR-National Institute of Nutrition, Hyderabad, India
| | - Rachakulla Harikumar
- Division of Community studies, ICMR-National Institute of Nutrition, Hyderabad, India
| | - Nimmathota Arlappa
- Division of Community studies, ICMR-National Institute of Nutrition, Hyderabad, India
| | - Indrapal Meshram
- Division of Community studies, ICMR-National Institute of Nutrition, Hyderabad, India
| | - Nagalla Balakrishna
- Division of statistics, ICMR-National Institute of Nutrition, Hyderabad, India
| | | | | | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,Harvard Center for Population and Development Studies, Cambridge, MA, USA
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13
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Efevbera Y, Bhabha J, Farmer P, Fink G. Girl child marriage, socioeconomic status, and undernutrition: evidence from 35 countries in Sub-Saharan Africa. BMC Med 2019; 17:55. [PMID: 30845984 PMCID: PMC6407221 DOI: 10.1186/s12916-019-1279-8] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Accepted: 02/01/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Girl child marriage, a formal union of a female before age 18, and undernutrition remain common in Sub-Saharan Africa. The aim of this study is to establish the extent to which girl child marriage contributes to socioeconomic status and underweight, a measure of undernutrition, among adult women. METHODS We used data from 103 Demographic and Health Surveys (DHS), representing 35 African countries from 1991 to 2014. Girl child marriage was coded both as a binary variable (before 18 years) and categorical variable (before 14, 14 to 15 years, 16 to 17 years). The primary outcome was underweight (body mass index less than 18·5). Secondary outcomes were early and multiple childbearing, secondary education completion, and wealth index. Logistic regression models were used to estimate associations. RESULTS Fifty-five percent of women married before age 18. Girl child marriage was associated with reduced risk of being underweight both in models adjusted for basic confounders (risk difference = - 0.020, 95% CI [- 0.026, - 0.014], p < 0.01) and in models adjusted for childbearing, women's relative status, and socioeconomic outcomes (risk difference = - 0.018, 95% CI [- 0.024, - 0.011], p < 0.01). Conditional on completing primary education and community fixed-effects, women married before 18 years had an increased risk of early motherhood (risk difference = 0.38, 95% CI [0.38, 0.38], p < 0.01) and of being in the poorest quintile (risk difference = 0.024, 95% CI [0.012, 0.036], p < 0.01), and were 27 percentage points less likely to complete secondary education (risk difference = - 0.27, 95% CI [- 0.28, - 0.26)], p < 001), compared to women married as adults. CONCLUSIONS Though associated with substantially reduced socioeconomic status, girl child marriage appears to be associated with slightly reduced risk of being underweight in the population studied. Further research is needed to understand the determinants of undernutrition in this context as well as the broader relationship between socioeconomic status and nutritional outcomes.
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Affiliation(s)
- Yvette Efevbera
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Ave, Bldg. 1, 11th floor, Boston, MA, 02115, USA.
| | - Jacqueline Bhabha
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Ave, Bldg. 1, 11th floor, Boston, MA, 02115, USA.,FXB Center for Health and Human Rights, Harvard T. H. Chan School of Public Health, 651 Huntington Ave, 7th Floor, Boston, MA, 02115, USA
| | - Paul Farmer
- Department of Global Health and Social Medicine, Harvard Medical School, 641 Huntington Ave, Boston, MA, 02115, USA
| | - Günther Fink
- Department of Global Health and Population, Harvard T. H. Chan School of Public Health, 665 Huntington Ave, Bldg. 1, 11th floor, Boston, MA, 02115, USA.,Swiss Tropical and Public Health Institute and University of Basel, Socinstrasse 57, 4051, Basel, Switzerland
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14
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The role of offspring’s birthweight on the association between pre-pregnancy obesity and offspring’s childhood anthropometrics: a mediation analysis. J Dev Orig Health Dis 2019; 10:570-577. [DOI: 10.1017/s2040174418001137] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AbstractWhile birthweight of offspring is associated with pre-pregnancy body mass index (BMI) and later risk of obesity, its mediating effect between the association of maternal pre-pregnancy BMI and offspring’s childhood anthropometrics has rarely been investigated. This study aimed to examine whether offspring birthweight is a mediator in the association between pre-pregnancy BMI and offspring’s childhood anthropometrics. The study included 1,618 mother–child pairs from the Australian Longitudinal Study on Women’s Health and Mothers and their Children’s Health Study. Children’s anthropometrics [mean age 8.6 (s.d. =3.0) years] were calculated from the mothers’ self-reported child weight and height measures. G-computation was used to estimate the natural direct and indirect (via birthweight) effects of pre-pregnancy BMI. In the fully adjusted model for maternal sociodemographic and lifestyle factors, the natural direct effects of pre-pregnancy obesity on child BMI-for-age, height-for-age, weight-for-age and weight-for-height outcomes were, β (95% confidence interval, CI), 0.75 (0.55, 0.95), 0.13 (−0.07, 0.32), 0.62 (0.44, 0.80) and 0.57 (0.24, 0.90), respectively. The corresponding natural indirect effects were 0.04 (−0.04, 0.12), −0.01 (−0.09, 0.07), −0.01 (−0.08, 0.07) and 0.09 (−0.05, 0.23). Similar results were observed for pre-pregnancy overweight and pre-pregnancy BMI as a continuous scale. Most of the effect of pre-pregnancy obesity on childhood weight-related anthropometric outcomes appears to be via a direct effect, not mediated through offspring’s birthweight.
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15
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Mejía-Guevara I, Corsi DJ, Perkins JM, Kim R, Subramanian SV. Variation in Anthropometric Status and Growth Failure in Low- and Middle-Income Countries. Pediatrics 2018; 141:peds.2017-2183. [PMID: 29472493 DOI: 10.1542/peds.2017-2183] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Addressing anthropometric failure in low- and middle-income countries can have 2 targets of inference: addressing differences between individuals within populations (Wpop) or differences between populations (Bpop). We present a multilevel framework to apply both targets of inference simultaneously and quantify the extent to which variation in anthropometric status and growth failure is reflective of undernourished children or undernourished populations. METHODS Cross-sectional data originated from the Demographic and Health Surveys program, covering children under age 5 from 57 countries surveyed between 2001 and 2015. RESULTS A majority of variation in child anthropometric status and growth failure was attributable to Wpop-associated differences, accounting for 89%, 83%, and 85% of the variability in z scores for height for age, weight for age, and weight for height. Bpop-associated differences (communities, regions, and countries combined) were associated with 11%, 17%, and 15% of the variation in height-for-age z score, weight-for-age z score, and weight-for-height z score. Prevalence of anthropometric failure was closely correlated with mean levels of height and weight. Approximately 1% of Wpop variability, compared with 30% to 50% of the Bpop variability, was explained by mean values of maternal correlates of anthropometric status and failure. Although there is greater explanatory power Bpop, this varied because of modifiability of what constitutes population. CONCLUSIONS Our results suggest that universal strategies to prevent future anthropometric failure in populations combined with targeted strategies to address both the impending and existing burden among children are needed.
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Affiliation(s)
- Iván Mejía-Guevara
- Department of Biology, Stanford University, Palo Alto, California.,Stanford Center for Population Health Sciences, School of Medicine, Stanford University, Stanford, California
| | - Daniel J Corsi
- OMNI Research Group, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Jessica M Perkins
- Department of Human and Organizational Development, Peabody College, Vanderbilt University, Nashville, Tennessee.,Vanderbilt Institute of Global Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rockli Kim
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; and
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts; and .,Harvard Center for Population and Development Studies, Harvard University, Cambridge, Massachusetts
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16
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McGovern ME, Krishna A, Aguayo VM, Subramanian SV. A review of the evidence linking child stunting to economic outcomes. Int J Epidemiol 2017; 46:1171-1191. [PMID: 28379434 PMCID: PMC5837457 DOI: 10.1093/ije/dyx017] [Citation(s) in RCA: 101] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2017] [Indexed: 11/15/2022] Open
Abstract
Background To understand the full impact of stunting in childhood it is important to consider the long-run effects of undernutrition on the outcomes of adults who were affected in early life. Focusing on the costs of stunting provides a means of evaluating the economic case for investing in childhood nutrition. Methods We review the literature on the association between stunting and undernutrition in childhood and economic outcomes in adulthood. At the national level, we also evaluate the evidence linking stunting to economic growth. Throughout, we consider randomized controlled trials (RCTs), quasi-experimental approaches and observational studies. Results Long-run evaluations of two randomized nutrition interventions indicate substantial returns to the programmes (a 25% and 46% increase in wages for those affected as children, respectively). Cost-benefit analyses of nutrition interventions using calibrated return estimates report a median return of 17.9:1 per child. Assessing the wage premium associated with adult height, we find that a 1-cm increase in stature is associated with a 4% increase in wages for men and a 6% increase in wages for women in our preferred set of studies which attempt to address unobserved confounding and measurement error. In contrast, the evidence on the association between economic growth and stunting is mixed. Conclusions Countries with high rates of stunting, such as those in South Asia and sub-Saharan Africa, should scale up policies and programmes aiming to reduce child undernutrition as cost-beneficial investments that expand the economic opportunities of their children, better allowing them and their countries to reach their full potential. However, economic growth as a policy will only be effective at reducing the prevalence of stunting when increases in national income are directed at improving the diets of children, addressing gender inequalities and strengthening the status of women, improving sanitation and reducing poverty and inequities.
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Affiliation(s)
- Mark E McGovern
- CHaRMS: Centre for Health Research at the Management School, Queen’s University Belfast
- UKCRC Centre of Excellence for Public Health (Northern Ireland)
| | - Aditi Krishna
- Harvard Center for Population and Development Studies
- Department of Social and Behavioral Sciences Harvard T.H. Chan School of Public Health
| | - Victor M Aguayo
- United Nations Children’s Fund (UNICEF), Nutrition Section, Programme Division, New York
| | - SV Subramanian
- Harvard Center for Population and Development Studies
- Department of Social and Behavioral Sciences Harvard T.H. Chan School of Public Health
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17
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Subramanian SV, Mejía‐Guevara I, Krishna A. Rethinking policy perspectives on childhood stunting: time to formulate a structural and multifactorial strategy. MATERNAL & CHILD NUTRITION 2016; 12 Suppl 1:219-36. [PMID: 27187918 PMCID: PMC5084745 DOI: 10.1111/mcn.12254] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Revised: 10/17/2015] [Accepted: 10/19/2015] [Indexed: 01/21/2023]
Abstract
Stunting and chronic undernutrition among children in South Asia remain a major unresolved global health issue. There are compelling intrinsic and moral reasons to ensure that children attain their optimal growth potential facilitated via promotion of healthy living conditions. Investments in efforts to ensure that children's growth is not faltered also have substantial instrumental benefits in terms of cognitive and economic development. Using the case of India, we critique three prevailing approaches to reducing undernutrition among children: an over-reliance on macroeconomic growth as a potent policy instrument, a disproportionate focus on interpreting undernutrition as a demand-side problem and an over-reliance on unintegrated single-factorial (one at a time) approaches to policy and research. Using existing evidence, we develop a case for support-led policy approach with a focus on integrated and structural factors to addressing the problem of undernutrition among children in India. Key messages Eliminating child undernutrition is important from an intrinsic perspective and offers considerable instrumental benefits to individual and society. Evidence suggests that an exclusive reliance on a growth-mediated strategy to eliminate stunting needs to be reconsidered, suggesting the need for a substantial support-led strategy. Interpreting and addressing undernutrition as a demand-side problem with proximal single-factorial interventions is futile. There is an urgent need to develop interventions that address the broader structural and upstream causes of child undernutrition.
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Affiliation(s)
- S V Subramanian
- Department of Social and Behavioral SciencesHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
- Child Health Evaluative Sciences and the Centre for Global Child HealthSickKids Research Institute, Hospital for Sick ChildrenTorontoONCanada
| | - Iván Mejía‐Guevara
- Child Health Evaluative Sciences and the Centre for Global Child HealthSickKids Research Institute, Hospital for Sick ChildrenTorontoONCanada
| | - Aditi Krishna
- Child Health Evaluative Sciences and the Centre for Global Child HealthSickKids Research Institute, Hospital for Sick ChildrenTorontoONCanada
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18
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Corsi DJ, Mejía-Guevara I, Subramanian SV. Improving household-level nutrition-specific and nutrition-sensitive conditions key to reducing child undernutrition in India. Soc Sci Med 2016; 157:189-92. [PMID: 26975835 DOI: 10.1016/j.socscimed.2016.02.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel J Corsi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
| | - Iván Mejía-Guevara
- Harvard Center for Population & Development Studies, Cambridge, MA, USA.
| | - S V Subramanian
- Harvard Center for Population & Development Studies, Cambridge, MA, USA; Department of Social and Behavioural Sciences, Harvard T H Chan School of Public Health, Harvard Center for Population and Development Studies, Boston, MA, USA.
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19
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Risk factors for chronic undernutrition among children in India: Estimating relative importance, population attributable risk and fractions. Soc Sci Med 2015; 157:165-85. [PMID: 26625852 DOI: 10.1016/j.socscimed.2015.11.014] [Citation(s) in RCA: 92] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Revised: 11/07/2015] [Accepted: 11/10/2015] [Indexed: 11/21/2022]
Abstract
Nearly 40% of the world's stunted children live in India and the prevalence of undernutrition has been persistently high in recent decades. Given numerous available interventions for reducing undernutrition in children, it is not clear of the relative importance of each within a multifactorial framework. We assess the simultaneous contribution of 15 known risk factors for child chronic undernutrition in India. Data are from the 3rd Indian National Family Health Survey (NFHS-3), a nationally representative cross-sectional survey undertaken in 2005-2006. The study population consisted of children aged 6-59 months [n = 26,842 (stunting/low height-for-age), n = 27,483 (underweight/low weight-for-age)]. Risk factors examined for their association with undernutrition were: vitamin A supplementation, vaccination, use of iodized salt, household air quality, improved sanitary facilities, safe disposal of stools, improved drinking water, prevalence of infectious disease, initiation of breastfeeding, dietary diversity, age at marriage, maternal BMI, height, education, and household wealth. Age/sex-adjusted and multivariable adjusted effect sizes (odds ratios) were calculated for risk factors along with Population Attributable Risks (PAR) and Fractions (PAF) using logistic regression. In the mutually adjusted models, the five most important predictors of childhood stunting/underweight were short maternal stature, mother having no education, households in lowest wealth quintile, poor dietary diversity, and maternal underweight. These five factors had a combined PAR of 67.2% (95% CI: 63.3-70.7) and 69.7% (95% CI: 66.3-72.8) for stunting and underweight, respectively. The remaining factors were associated with a combined PAR of 11.7% (95% CI: 6.0-17.4) and 15.1% (95% CI: 8.9-21.3) for stunting and underweight, respectively. Implementing strategies focused on broader progress on social circumstances and infrastructural domains as well as investments in nutrition specific programs to promote dietary adequacy and diversity are required to ensure a long term trajectory of optimal child growth and development in India.
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20
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Corsi DJ, Subramanian SV, Ackerson LK, Davey Smith G. Is there a greater maternal than paternal influence on offspring adiposity in India? Arch Dis Child 2015; 100:973-9. [PMID: 26044138 DOI: 10.1136/archdischild-2014-307690] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 05/09/2015] [Indexed: 11/03/2022]
Abstract
Previous research has provided conflicting evidence regarding fetal roots of adiposity in India. To compare the strength of association between maternal and paternal body mass indexes (BMIs) corrected for height with offspring BMI in India to examine the potential for intrauterine mechanisms to influence offspring adiposity in India, we analysed a sample of 16,528 mother-father-offspring trios from the 2005 to 2006 Indian National Family Health Survey. Children were aged 0-59 months with parents aged 15-49 years (mothers) and 15-54 years (fathers). Linear and logistic regression models, specified in multiple ways, were used to estimate associations between parental BMI* (BMI redefined by power term x (kg/m(x)) to be independent from height), and child BMI/top decile of child BMI. Higher values of maternal BMI and paternal BMI were associated with higher values of offspring BMI. In comparing the effects of maternal BMI and paternal BMI, however, no consistent differences were found in the strength of these parental influences on offspring BMI. In the fully adjusted linear model, the standardised coefficient was 0.131 (95% CI 0.110 to 0.154) for maternal BMI* and 0.079 (95% CI 0.056 to 0.103) for paternal BMI*; with evidence of heterogeneity between maternal-offspring and paternal-offspring associations (p=0.005). This was not robust in the unstandardised regression (β=0.056, 95% CI 0.044 to 0.067 for maternal BMI and β=0.039, 95% CI 0.025 to 0.053 for paternal BMI, p=0.093). Mixed results indicate that compared with paternal BMI, maternal BMI did not have a consistently stronger influence on offspring BMI in India.
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Affiliation(s)
- Daniel J Corsi
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - S V Subramanian
- Department of Social and Behavioral Sciences, Harvard T H Chan School of Public Health, Boston, Massachusetts, USA Harvard Center for Population & Development Studies, Cambridge, Massachusetts, USA
| | - Leland K Ackerson
- Department of Community Health and Sustainability, University of Massachusetts Lowell, Lowell, Massachusetts, USA
| | - George Davey Smith
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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21
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Corsi DJ, Neuman M, Finlay JE, Subramanian SV. Demographic and health surveys: a profile. Int J Epidemiol 2012; 41:1602-13. [PMID: 23148108 DOI: 10.1093/ije/dys184] [Citation(s) in RCA: 640] [Impact Index Per Article: 53.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Demographic and Health Surveys (DHS) are comparable nationally representative household surveys that have been conducted in more than 85 countries worldwide since 1984. The DHS were initially designed to expand on demographic, fertility and family planning data collected in the World Fertility Surveys and Contraceptive Prevalence Surveys, and continue to provide an important resource for the monitoring of vital statistics and population health indicators in low- and middle-income countries. The DHS collect a wide range of objective and self-reported data with a strong focus on indicators of fertility, reproductive health, maternal and child health, mortality, nutrition and self-reported health behaviours among adults. Key advantages of the DHS include high response rates, national coverage, high quality interviewer training, standardized data collection procedures across countries and consistent content over time, allowing comparability across populations cross-sectionally and over time. Data from DHS facilitate epidemiological research focused on monitoring of prevalence, trends and inequalities. A variety of robust observational data analysis methods have been used, including cross-sectional designs, repeated cross-sectional designs, spatial and multilevel analyses, intra-household designs and cross-comparative analyses. In this profile, we present an overview of the DHS along with an introduction to the potential scope for these data in contributing to the field of micro- and macro-epidemiology. DHS datasets are available for researchers through MEASURE DHS at www.measuredhs.com.
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Affiliation(s)
- Daniel J Corsi
- Harvard Center for Population and Development Studies, Harvard University, Boston, MA 02115, USA
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