Development of a diagnostic predictive model for determining child stunting in Malawi: a comparative analysis of variable selection approaches.

BACKGROUND: Childhood stunting is a major indicator of child malnutrition and a focus area of Global Nutrition Targets for 2025 and Sustainable Development Goals. Risk factors for childhood stunting are well studied and well known and could be used in a risk prediction model for assessing whether a child is stunted or not. However, the selection of child stunting predictor variables is a critical step in the development and performance of any such prediction model. This paper compares the performance of child stunting diagnostic predictive models based on predictor variables selected using a set of variable selection methods. METHODS: Firstly, we conducted a subjective review of the literature to identify determinants of child stunting in Sub-Saharan Africa. Secondly, a multivariate logistic regression model of child stunting was fitted using the identified predictors on stunting data among children aged 0-59 months in the Malawi Demographic Health Survey (MDHS 2015-16) data. Thirdly, several reduced multivariable logistic regression models were fitted depending on the predictor variables selected using seven variable selection algorithms, namely backward, forward, stepwise, random forest, Least Absolute Shrinkage and Selection Operator (LASSO), and judgmental. Lastly, for each reduced model, a diagnostic predictive model for the childhood stunting risk score, defined as the child propensity score based on derived coefficients, was calculated for each child. The prediction risk models were assessed using discrimination measures, including area under-receiver operator curve (AUROC), sensitivity and specificity. RESULTS: The review identified 68 predictor variables of child stunting, of which 27 were available in the MDHS 2016-16 data. The common risk factors selected by all the variable selection models include household wealth index, age of the child, household size, type of birth (singleton/multiple births), and birth weight. The best cut-off point on the child stunting risk prediction model was 0.37 based on risk factors determined by the judgmental variable selection method. The model's accuracy was estimated with an AUROC value of 64% (95% CI: 60%-67%) in the test data. For children residing in urban areas, the corresponding AUROC was AUC = 67% (95% CI: 58-76%), as opposed to those in rural areas, AUC = 63% (95% CI: 59-67%). CONCLUSION: The derived child stunting diagnostic prediction model could be useful as a first screening tool to identify children more likely to be stunted. The identified children could then receive necessary nutritional interventions.

Perspective: Connecting the dots between domestic livestock ownership and child linear growth in low- and middle-income countries.

Child stunting due to linear growth faltering remains a pervasive issue in low- and middle-income countries. Two schools of thought have existed pertaining to the role of domestic livestock ownership (DLO) in child linear growth. On one hand, it is argued that DLO leads to greater income and financial security, resulting in better child-raising conditions, including greater animal-source food (ASF) consumption, having protective effects towards child stunting. On the other hand, researchers argue that DLO contributes to faecal contamination and transmission of zoonotic enteric infections from animals to children, thus having destructive effects on child growth. Reviews of this association have revealed ambiguous findings. In this perspective, we argue that measuring the association between exposures to domesticated animals and child stunting is difficult and the ambiguous associations revealed are a result of confounding and differences in the management of DLO. We also argue that the increasingly prominent area of research of environmental enteric dysfunction, a sub-clinical condition of the small intestine thought to be due to frequent faecal pathogen exposure and associated with stunting, will be a useful tool to measure the potential destructive effects of DLO on child growth. We present our argument and identify challenges and considerations and directions for future research.

Local contextual factors of child stunting found via shared values of stakeholder groups: an exploratory case study in Kaffrine, Senegal.

OBJECTIVE: This work aims to demonstrate an original approach to identify links between locally situated shared values and contextual factors of stunting. Stunting results from multi-factorial and multi-sectoral determinants, but interventions typically neglect locally situated lived experiences, which contributes to problematic designs that are not meaningful for those concerned and/or relatively ineffective. DESIGN: This case study investigates relevant contextual factors in two steps: by first facilitating local stakeholder groups (n 11) to crystallise their shared-values-in-action using a specialised method from sustainability studies (WeValue_InSitu (WVIS)). Secondly, participants (n 44) have focus group discussions (FGD) about everyday practices around child feeding/food systems, education and/or family life. Because the first step strongly grounds participants in local shared values, the FGD can reveal deep links between contextual factors and potential influences on stunting. SETTING: Kaffrine, Senegal, an 'Action Against Stunting Hub' site. December 2020. PARTICIPANTS: Eleven stakeholder groups of mothers, fathers, grandmothers, pre-school teachers, community health workers, farmers, market traders and public administrators. RESULTS: Local contextual factors of stunting were identified, including traditional beliefs concerning eating and growing practices; fathers as decision-makers; health worker trust; financial non-autonomy for women; insufficient water for preferred crops; merchants' non-access to quality produce; religious teachings and social structures affecting children's food environment. CONCLUSIONS: Local contextual factors were identified. Pre-knowledge of these could significantly improve effectiveness of intervention designs locally, with possible applicability at other sites. The WVIS approach proved efficient and useful for making tangible contextual factors and their potential links to stunting, via a lens of local shared values, showing general promise for intervention research.

Water, sanitation, and hygiene vulnerability in child stunting in developing countries: a systematic review with meta-analysis.

OBJECTIVES: This study aimed to perform a systematic review and meta-analysis to assess the scientific evidence of the relationship between vulnerability to access to safe drinking water, sanitation, and hygiene (WASH) practices on stunting in children aged <5 years in developing countries. STUDY DESIGN: This is a systematic review and meta-analysis article to assess the relationship between under-five stunting and WASH vulnerability in developing countries. METHODS: The systematic review with meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol methodology. The following databases were used: LILACS, MEDLINE (via PubMed), SciELO, Web of Science, ScienceDirect, SCOPUS, and Embase. All original studies identified that related WASH vulnerability to stunting in children aged <5 years in developing countries was included. Three authors performed independently the selection and extraction of data from the articles. The statistical software STATA version 11 was used. Cochran's Q test and Chi-square test (I2) with 95% significance were used to assess the heterogeneity of the studies. RESULTS: The search resulted in the initial identification of 2047 articles; after reading the abstracts, followed by the full articles, 14 articles were included in the systematic review and eight articles were included in the meta-analysis. The studies selected for the systematic review were published between the years 1992 and 2021 and conducted in eight countries, namely, Ethiopia, India, Indonesia, Bangladesh, Tanzania, Peru, China, and Lesotho. The studies assessed vulnerability to access to WASH on the growth of children aged <5 years. There was a significant difference when relating WASH vulnerability to children's height. The meta-analysis of this study showed that the impact of WASH on child stunting is significant when it comes to lack of sanitation in 72% of the studies. CONCLUSIONS: The study found that WASH vulnerability contributes to stunting in children aged <5 years in developing countries. Based on our findings, we recommend incorporating WASH strategies, especially sanitation, into the formulation of interventions integrating with health promotion policies for healthy early childhood development.

Child Stunting Reduction in Aceh Province: Challenges and a Way Ahead.

INTRODUCTION: Indonesia ranks the fifth highest in child stunting among Asian countries. Aceh, a westernmost province in Indonesia recorded the highest prevalence of stunting in children under two years old in the nation. Our study investigated the current government efforts on child stunting reduction activities since the introduction of Governor Regulation No. 14/2019. METHODS: The study investigated the current efforts of Aceh governments and relevant actors on child stunting reduction using in-depth interviews, document reviews and focus group discussions. RESULTS: Thirty-five (35) respondents including policy makers were interviewed, four focus group discussions (15 each group) were conducted, and various official documents were reviewed. Various challenges for reducing child stunting in Aceh were identified: inadequate knowledge and skills of Posyandu cadres on child stunting; reluctance to consume iron and folic acid (IFA), and supplementary foods (PMT Bumil) by many pregnant women due to perceived annoying effects and unappetizing taste; work engagement, insufficient breast milk production and inadequate support from husbands failing to achieve exclusive breastfeeding among nursing women; inadequate provision of complementary fortified foods for children 6-23 months; lack of clean water, waste management and WASH practices. CONCLUSION: The intervention on both nutrition-specific and nutrition-sensitive factors was found to be insufficient in Aceh. Although WASH (water, sanitation and hygiene) practices are the most important contributors to child stunting, only the health agency plays a singular role in reduction efforts by focussing on specific factors. Coordination between relevant agencies to address both factors is required to achieve the effectiveness of child stunting reduction and prevention in Aceh.

Association between mother's work status and child stunting in urban slums: a cross-sectional assessment of 346 child-mother dyads in Dhaka, Bangladesh (2020).

BACKGROUND: A growing literature highlights the increased risk of stunting among children growing up in informal or slum settlements. Despite relatively high rates of female labor force participation in slums, there is limited evidence on relationship between mother's work participation and nutritional outcomes of children in these settings. METHODS: We conducted a cross-sectional study in two large slums (Korail and Tongi) of Dhaka and Gazipur, Bangladesh to assess the association between maternal work and childhood stunting in a low-income urban context. Logistic regression models estimated unconditional and conditional associations between maternal work status and 1) child stunting, 2) child morbidity and dietary intake, and 3) health and hygiene behaviors. Subgroup analyses were done by type of child care support available. RESULTS: After adjusting for variations in individual and household level characteristics, we found that children of working mothers had nearly twice the odds of being stunted than children of non-working mothers (OR 1.84, 95%CI 1.05-3.23). Large differences in stunting were found by available care support: compared to children of non-working mothers, children of working mothers with nuclear-type family support had 4.5 times increased odds of stunting (OR 4.49, 95%CI 1.81-11.12), while no odds differential was found for children of working mothers with an extended-type family support (OR 0.69, 95%CI 0.30-1.59). CONCLUSIONS: Maternal employment is associated with a substantial increase in the odds of child stunting in the slum areas studied. Given that these effects only appear to arise in the absence of adequate family support, integrating appropriate childcare support measures for low-income urban working mothers might be an effective strategy to help reduce the prevalence of chronic undernutrition among slum children.

Risk factors for child stunting in Bangladesh: an analysis using MICS 2019 data.

BACKGROUND: Malnutrition is considered a major public health challenge and is associated with a range of health issues, including childhood stunting. Stunting is a reliable and well-recognized indicator of chronic childhood malnutrition. The objective of this study is to determine the risk factors associated with stunting among 17,490 children below five years of age in Bangladesh. METHODS: Correlates of child stunting were examined using data generated by a cross-sectional cluster survey conducted in Bangladesh in 2019. The data includes a total of 17,490 children (aged < 5 years) from 64,400 households. Multiple logistic regressions were used to determine the risk factors associated with child stunting and severe stunting. RESULTS: The prevalence of stunting and severe stunting for children was 25.96% and 7.97%, respectively. Children aged 24 to < 36 months [Odds Ratio (OR) = 2.65, 95% CI: 2.30, 3.05] and aged 36 to < 48 months [OR = 2.33, 95% CI: 2.02, 2.69] had more risk of stunting compared to the children aged < 6 months. Children from Sylhet division had the greatest risk of stunting of all the eight divisions [OR = 1.26, 95% CI: 1.09, 1.46]. Children of secondary complete or higher educated mothers were less likely to develop stunting [OR = 0.66, 95% CI: 0.56, 0.79] compared with children of mothers having no education at all. Similarly, children of secondary complete or higher educated father [OR = 0.74, 95% CI: 0.63, 0.87] were found to have lower risk of stunting compared with children whose father hadn't any education. Substantially lower risk of stunting was observed among children whose mother and father both completed secondary education or above [OR = 0.59, 95% CI: 0.52, 0.69]. Children from the richest households [OR = 0.49, 95% CI: 0.41, 0.58] had 51% lower odds of stunting compared to children from the poorest households. CONCLUSIONS: After controlling for socioeconomic and demographic factors, parental education and household position in the wealth index were found to be the most important determinants of child stunting in Bangladesh.

The Shishu Pushti Trial-Extended Peer Counseling for Improving Feeding Practices and Reducing Undernutrition in Children Aged 0-48 Months in Urban Bangladesh: Protocol for a Cluster-Randomized Controlled Trial.

BACKGROUND: The aim of this study is to assess if peer counseling of women improves breastfeeding, complementary feeding practices, and child growth, and thus reduces the prevalence of undernutrition in children up to 4 years of age. OBJECTIVE: Lack of exclusive breastfeeding and inappropriate complementary feeding are critical factors in reducing child undernutrition, morbidity, and mortality. There are reported trials of peer counseling to improve breastfeeding; however, they did not examine the efficacy of peer counseling to improve complementary feeding or the long-term impacts on child growth and development. METHODS: This study has used a community-based, cluster-randomized controlled trial with a superiority design and 2 parallel treatment arms. It is assessing the impact of peer counseling, starting in late pregnancy up to 1 year after delivery, on child feeding practices, growth, and development with follow-up until 48 months of age. The study site was Mirpur, a densely populated area in Dhaka. Using satellite maps and geographic information system mapping, we constructed 36 clusters with an average population of 5000 people. We recruited pregnant women in the third trimester aged 16-40 years, with no more than 3 living children. Trained peer counselors visited women at home twice before delivery, 4 times in the first month, monthly from 2 to 6 months, and again at 9 and 12 months. Trained research assistants collected anthropometric measurements. The primary outcome will be differences in child stunting and mean length for age at 6, 12, 15, and 18 months. Secondary outcomes will be differences in the percentage of women exclusively breastfeeding in the mean duration of any breastfeeding and in the percentage of children at 6 and 9 months of age who receive solid, semisolid, or soft foods; and the percentage of children consuming foods from 4 or more food groups at 9, 12, 15, and 18 months. We will assess the mean cognitive function scores from the Ages and Stages Questionnaire (9 and 18 months) and Bayley tests (24 and 36 months). RESULTS: We identified 65,535 people in mapped residences, from which we defined 36 clusters and randomly allocated them equally to intervention or control groups stratified by cluster socioeconomic status. From July 2011 to May 2013, we identified 1056 pregnant women and 993 births in the intervention group and 994 pregnancies and 890 births in the control group. At 18 months, 692 children remained in the intervention group and 551 in the control group. From January 2015 to February 2017, we conducted the long-term follow-up of the cohort. We have now completed the data collection and processing and have started analyses. CONCLUSIONS: This study will help fill the evidence gap about the short- and long-term impact of peer counseling on improving infant feeding, preventing childhood undernutrition, and enhancing child cognitive development. TRIAL REGISTRATION: ClinicalTrials.gov NCT01333995; https://clinicaltrials.gov/ct2/show/NCT01333995. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/31475.

Child stunting and associated risk factors in selected food-insecure areas in Rwanda: an analytical cross-sectional study.

Introduction: stunting rates among the under-five children are generally high in Rwanda. They are unexpectedly lower than the national average stunting rate in some districts where poverty rates are the highest in the country. This study aimed to ascertain the key factors that protect children from stunting in these poorest areas, where stunting rates are lower than expected. Methods: we analysed cross-sectional data from 2019/2020 Rwanda Demographic and Health Survey (RDHS) for 477 under-five children from Karongi, Rulindo, Nyanza, and Gisagara districts. Univariate and bivariate statistical analyses were used to find out the factors to retain for multivariable analysis. We obtained the key risk factors of child stunting through a multivariable binary logistic regression analysis. Results: the child stunting rate in the study districts was 30 percent, which is three percent lower than the national average rate. Child stunting was negatively associated with a birth weight of at least 2.5 kg (AOR = 0.393, 95% CI: 0.180 - 0.856), a high household economic status (AOR = 0.506, 95%CI: 0.273 - 0.937), urban residence (AOR = 0.467; 95% CI: 0.222 - 0.984), and health insurance coverage (AOR = 0.418; 95% CI: 0.228 -0.767). Children aged one year and above, as well as female-headed households, were associated with at least three times and two times greater odds of child stunting than children aged below 12 months and those from male-headed households respectively. Conclusion: the nutritional performance of children in the study districts is substantially driven by the high uptake of health insurance, which fosters increased access to healthcare services. To address child-stunting gaps in low-income areas in Rwanda, child nutrition programs should improve the utilization of healthcare services, and leverage the potential high effect of nutrition education, especially during pregnancy and lactation.

Effects of parental stature on child stunting in India.

Adult heights in India are short. Child stunting remains high though the prevalence fell from 48% to 38% in the decade prior to 2016. This study assesses the links between parental height and child stunting using nationally representative data on 28,975 under-five-year-old children from the 2015-16 National Family Health Survey. Parental heights are represented as quintiles. Logistic regression was applied to estimate the effect of parental heights after adjustment for household wealth, parental schooling, place of residence and other covariates. The unadjusted estimates showed the effect on stunting to be similar for maternal height, wealth and education. In the multivariate analysis maternal height emerged as the strongest predictor of stunting, with adjusted odds of 2.85 for the shortest compared with the tallest quintile. The two other strong predictors of stunting were paternal height and wealth, with adjusted odds of close to 2.0 for the lowest quintile relative to the highest quintiles. In comparison, associations between stunting and other factors were minor, with the partial exception of mother's education. The findings underscore the key role of intergenerational influences on stunting. Maternal height has a stronger association with childhood stunting than paternal height and socioeconomic influences such as education and household wealth. The influence of paternal height is also strong, equal in magnitude to household wealth. Health workers need to be alerted to the special needs of short women.

Trends of Stunting Prevalence and Its Associated Factors among Nigerian Children Aged 0-59 Months Residing in the Northern Nigeria, 2008-2018.

Every year in Nigeria, malnutrition contributes to more than 33% of the deaths of children below 5 years, and these deaths mostly occur in the northern geopolitical zones (NGZs), where nearly 50% of all children below 5 years are stunted. This study examined the trends in the prevalence of stunting and its associated factors among children aged 0-23 months, 24-59 months and 0-59 months in the NGZs. The data of 33,682 recent live births in the NGZs, extracted from the Nigeria Demographic and Health Surveys from 2008 to 2018, were used to investigate the factors associated with stunting using multilevel logistic regression. Children aged 24-59 months reported the highest prevalence of stunting, with 53.3% (95% confidence interval: 52.0-54.6%). Multivariable analyses revealed four common factors that increased the odds of a child's stunting across all age subgroups: poor households, geopolitical zone (northwest or northeast), being a male and maternal height (<145 cm). Interventional strategies focused on poverty mitigation through cash transfer and educating low socioeconomic mothers on the benefits of gender-neutral supplementary feeding and the timely monitoring of the offspring of short mothers would substantially reduce stunting across all age subgroups in the NGZs.

Progress in child stunting across the world from 1990 to 2015: testing the global convergence hypothesis.

OBJECTIVE: This study has two-fold objectives: first, to test the global convergence hypothesis in the progress of child stunting across 174 countries over the period 1990-2015; second, to identify factors determining the process of convergence or divergence. DESIGN: The study design comprises macro-level cross-country analyses. Our empirical strategy uses parametric convergence models such as absolute and conditional ß-convergence models, while non-parametric convergence models such as Kernel density plots serve as robustness checks. SETTING: The study uses a global setting comprising child stunting information from 174 countries. PARTICIPANTS: The participants for this study are 174 countries. The information on child stunting prevalence for most countries is available from the UNICEF-WHO-WB Joint Child Malnutrition Estimates Expanded Database (April-2019), while national-level surveys are used for those countries where UNICEF-WHO-WB Database is not available. The data for socio-economic variables are taken from the World Bank's data bank (1990-2015). RESULTS: Findings from the absolute ß-convergence model estimates show that progress in child stunting has diverged over the entire period (1990-2015). However, the speed of divergence has reduced for the recent period (2010-2015). The conditional ß-convergence model estimates show that cross-country heterogeneity in GDP per capita, poverty and health care expenditure are significant factors explaining divergence in child stunting. CONCLUSIONS: For replacing current divergence with convergence in child stunting worldwide, the study demonstrates the critical role of economic factors and public spending on health care to reduce child stunting, particularly in countries where progress is slow.

Gender dimensions of the impact of HIV/AIDS on stunting in children under five years in Zimbabwe.

BACKGROUND: HIV/AIDS can have a disastrous effect on household food and nutrition security outcomes such as stunting in children under 5. However, stunting and HIV/AIDS are highly gendered phenomena that need to be explored in order to get an in-depth understanding of the interrelationship. This study was therefore aimed at investigating gender dimensions of the impact of HIV/AIDS on stunting in children under 5 years in Zimbabwe. METHODS: The study uses a large scale nationally representative cross-sectional dataset of 13,854 Zimbabwean households for the year 2019. To test hypothesis 1, the study employs binary choice models (Probit and Logit) since the outcome variable household HIV/AIDS status is dichotomous. To test hypothesis 2 and 3, the study employs the Propensity Score Matching (PSM) approach to circumvent the self-selection problem in the creation of treatment and control groups for households affected by HIV/AIDS and those that are not. RESULTS: The results revealed that household HIV/AIDS status is independent of the gender of household head. On the other hand, the results for the PSM estimates show that the probability of the household having a stunted child under 5 years is higher for households with an HIV positive member compared to those without. In addition, female headed households with an HIV positive member are more likely to have a stunted child under 5 years compared to male headed households under similar circumstances. CONCLUSION: Overall, the results provide evidence of a higher risk of stunting among children from households affected by HIV/AIDS. The study offers three major findings. Firstly, the study finds no significant association between gender of the household head and household HIV/AIDS status. Secondly, households that have at least one HIV positive member are more likely to have a stunted child under 5 years. Lastly, female headed households with at least one HIV positive member are more likely to have a stunted child under 5 years compared to male headed household with similar HIV/AIDS status. The findings have important policy implications towards improved integration of HIV/AIDS status, household head gender and child nutrition services in affected households.

Child Undernutrition following the Introduction of a Large-Scale Toilet Construction Campaign in India.

BACKGROUND: Lack of toilets and the widespread practice of open defecation may contribute to India's large burden of child undernutrition. OBJECTIVES: We examine whether a large national sanitation campaign launched in 2014, the Swachh Bharat Mission (SBM), precedes a reduction in stunting and wasting among under 5-y-old (u5) children in India. METHODS: In this observational study, we used district-level data from before (2013-2014) and after (2015-2016) SBM from 3 national surveys to derive, as our outcomes, the percentage of u5 children per district who are stunted and wasted. We defined our exposures as 1) binary indicator of SBM and 2) percentage of households with toilets per district. Our analytic sample comprised nearly all 640 Indian districts (with ∼1200 rural/urban divisions per district per time point). Linear regression analyses controlled for baseline differences in districts, linear time trends by state, and relevant covariates. RESULTS: Relative to pre-SBM, u5 stunting declines by 0.06% (95% CI: -0.10, -0.01; P = 0.009) with every percentage increase in households with toilets post-SBM. Rural regions and districts with higher pre-SBM toilet availability show greater decline in u5 stunting post-SBM. CONCLUSIONS: An increase in toilet availability on a national scale, precipitated by the SBM sanitation campaign, is associated with a reduction in undernutrition among u5 children in India over the early phase of the campaign.

Socio-economic status and the double burden of malnutrition in Cambodia between 2000 and 2014: overweight mothers and stunted children.

OBJECTIVE: The Cambodian population has experienced an increase in the proportion of stunted children who have overweight mothers during a period of rapid social and economic growth. We aimed to identify socio-economic factors associated with this household-level double burden over time. DESIGN: We used data from four Cambodia Demographic and Health Surveys from 2000 to 2014 to study the impact of socio-economic status (SES) on the link between child stunting and overweight mothers in two periods 2000-2005 v. 2010-2014. We hypothesised that SES would be a primary factor associated with this phenomenon. PARTICIPANTS: We included 14 988 children under the age of 5 years, among non-pregnant mothers aged 15-49 years of age and conducted analysis on a subsample of 1572 children with overweight mothers. SETTING: Nationally representative household survey across all regions. RESULTS: SES factors, specifically household wealth and maternal employment in service or manual occupations (in 2010-2014), are the main drivers of stunting among children of overweight mothers. Children with overweight mothers in the poorest households are more than twice as likely to be stunted than in the richest in both periods (2000-2005: adjusted OR (aOR) = 2·53, 95 % CI: 1·25, 5·13; 2010-2014: aOR = 2·61, 95 % CI: 1·43, 4·77), adjusting for other SES factors, indicating that despite decreasing income inequality, the poorest continue to bear excess risk of a double burden of malnutrition. Maternal short stature also doubled the likelihood of child stunting in both periods, which suggests intergenerational transmission of adversity and physical underdevelopment. CONCLUSIONS: Socio-economic inequalities should be addressed to reduce disparities in the household-level double burden of malnutrition.

Prevalence and regional variations of coexistence of child stunting and maternal overweight or obesity in Myanmar.

OBJECTIVE: The current study aimed to investigate double burden of malnutrition within households at the national and subnational levels and to identify its association with sociodemographic factors in Myanmar. DESIGN: All the variables were extracted from children's file of the Myanmar Demographic and Health Survey 2015-2016. Children under five were identified as stunted based on a height-for-age < -2 sd below the WHO reference median. Maternal overweight/obesity was defined as a BMI ≥ 23 kg/m2. A stunted child with an overweight/obese mother (SCOM) was classified as a double-burden household. SETTING: A national household survey in Myanmar. PARTICIPANTS: Children under five and their mothers (n 3954 pairs). RESULTS: Mean ages of children and mothers were 29 (se 0·14) months and 30·9 (se 0·32) years, respectively. National prevalence of childhood stunting and maternal overweight/obesity was 28·0 % and 39·4 %, respectively, and the prevalence of SCOM was 9·1 %. Significant regional differences were found in SCOM, ranging from 3·6 % in Naypyitaw to 12 % in Kachin and Mon and 14·6 % in Kayah. In the multinomial logistic regression analysis, relative to neither a stunted child nor an overweight/obese mother, child's age, maternal age, maternal experience of a teen birth, short mothers, mothers with primary education and in middle or rich wealth tertiles, and some regions (Kachin, Kayah, Shan, Sagaing, Taninthayi, Ayeyarwaddy, Mon and Yangon) were associated with greater odds of SCOM. CONCLUSIONS: The current study showed a relatively high national prevalence of SCOM and significant regional variations. Overarching policies and programmes with culturally sensitive strategies need to be formulated and implemented.

Investigating the Relationship between Food Insecurity and Fertility Preferences in Tanzania.

OBJECTIVE: We analyze fertility preferences among women at risk of pregnancy with children ages five or younger as a function of two food security metrics: perceptions of household hunger and child stunting (height for age z scores ≤ -2.0) in order to convey a robust picture of food insecurity. METHODS: We use data from the 2016 Tanzania Demographic and Health Surveys to analyze this research question. Multinomial generalized logit models with cluster-adjusted standard errors are used to determine the association between different dimensions of food insecurity and individual-level fertility preferences. RESULTS: On average, women who experience household hunger are 19% less likely to want more children compared to women who do not experience household hunger (AOR: 0.81, p = 0.02) when controlling for education, residence, maternal age, number of living children, and survey month. Adjusting for the same covariates, having at least one child ≤ 5 years old who is stunted is associated with 13% reduced odds of wanting more children compared to having no children stunted (AOR: 0.87, p = 0.06). CONCLUSIONS FOR PRACTICE: In the context of a divided literature base, this research aligns with the previous work identifying a preference among women to delay or avoid pregnancy during times of food insecurity. The similarity in magnitude and direction of the association between food insecurity and fertility preferences across the two measures of food insecurity suggest a potential association between lived or perceived resource insecurity and fertility aspirations. Further research is needed in order to establish a mechanism through which food insecurity affects fertility preferences. SIGNIFICANCE STATEMENT: Individual fertility preferences are sensitive to dynamic multi-level factors in a woman's life. While qualitative research has explored the effect that food insecurity and associated resource constraints have on fertility preferences, results are conflicting. Here, we quantitatively examine how individual woman's fertility preferences associate with two measures of food insecurity and qualitatively compare the associations across food insecurity measures. We establish that two food insecurity measures- household hunger and child stunting- capture similar populations and have similar associations with fertility preferences. This is a critical step forward in understanding the dynamic relationship between resource availability, child well-being, and fertility preferences.

Equity and Distributional Impact on Stunting of a Nutritional Package Targeting Children Aged 6-36 Months in China: Findings from a Modeling Study.

BACKGROUND: Despite rapid economic development, child stunting remains a persistent problem in China. Stunting prevalence varies greatly across geographical regions and wealth groups. To address child undernutrition, the Ying Yang Bao (YYB) nutritional package has been piloted in China since 2001. OBJECTIVE: We aimed to evaluate the distributional impact of a hypothetical rollout of the YYB nutritional package on child stunting across provinces and wealth groups in China, with a specific focus on equity. METHODS: We used data from China Family Panel Studies and built on extended cost-effectiveness analysis methods. We estimated the distributional impact of a 12-month YYB program targeting children aged 6-36 months across 25 provinces and two wealth groups along three dimensions: the cost of the YYB program; the number of child stunting cases averted by YYB; and the cost per stunting case averted. Children in each province were divided into poverty and non-poverty groups based on the international poverty line of $5.50 per day. We also conducted a range of sensitivity analyses. RESULTS: We showed that 75% coverage of YYB could avert 1.9 million stunting cases among children aged 6-36 months, including 1.3 million stunting cases among children living under the poverty line, at a total cost of ¥5.4-6.2 billion ($1.5-1.8 billion) depending on the type of YYB delivery. The cost per stunting case averted would greatly vary across Chinese provinces and wealth groups, ranging from ¥800 (around $220, Chongqing province) to ¥23,300 (around $6600, Jilin province). In most provinces, the cost per stunting case averted would be lower for children living under the poverty line. CONCLUSIONS: YYB could be a pro-poor nutritional intervention package that brings substantial health benefits to poor and marginalized Chinese children, but with large variations in value for money across provinces and wealth groups. This analysis points to the need for prioritization across provinces and a targeted approach for YYB rollout in China.

Stunted from the start: Early life weather conditions and child undernutrition in Ethiopia.

This paper examines the relationship between weather conditions and child nutrition in Ethiopia. We link data from four rounds of the Ethiopia Demographic and Health Survey to high-resolution climate data to measure exposure to rainfall and temperature in utero and during early life. We then estimate a set of multivariate regression models to understand how weather conditions impact child stunting, an indicator of sustained early life undernutrition. We find that greater rainfall during the rainy seasons in early life is associated with greater height for age. In addition, higher temperatures in utero, particularly during the first and third trimesters, and more rainfall during the third trimester, are positively associated with severe stunting, though stunting decreases with temperature in early life. We find potential evidence for a number of pathways underlying the weather-child nutrition relationship including agricultural livelihoods, heat stress, infectious disease transmission, and women's time use during pregnancy. These findings illuminate the complex pathways through which climate change may influence child health and should motivate additional research focused on identifying the causal mechanisms underlying these links.

The impact of food fortification on stunting in Zimbabwe: does gender of the household head matter?

BACKGROUND: High prevalence of stunting in children under 5 years poses a major threat to child development in developing countries. It is associated with micronutrient deficiency arising from poor diets fed to children under 5 years. Food fortification is amongst the interventions focused at reducing the incidence of stunting in children under 5 years. METHODS: Using a large-scale household data from Zimbabwe, we investigated the gender-based importance of household adoption of food fortification on the proportion of stunted children in the household. We employed propensity score matching to mitigate self-selection bias associated with household adoption of food fortification. RESULTS: We offer three major findings. Firstly, we find statistically weak evidence that female headed households are more likely to adopt food fortification than their male counterparts. Secondly, food fortification reduces the proportion of stunted children in the household. Finally, in comparison to non-adopters, female headed households that adopt food fortification are more able to reduce the proportion of stunted children in their households than their male counterparts. CONCLUSION: The results highlight the need for policy makers to actively promote food fortification, as such interventions are likely to contribute to the reduction of stunting and to involve men in fortification interventions to improve on their knowledge and appreciation of fortified foods and the associated benefits.