Abstract
BackgroundThe 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.MethodsWe 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.ResultsMost 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.ConclusionsPolicies 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.
Highlights
Poor nutritional status in early childhood remains highly prevalent in low- and middle-income countries (LMICs)[1,2] despite continued attention by global agencies, as exemplified by the Millennium Development Goals,[3] Global Nutrition Targets 2025,4 and Sustainable Development Goals,[5] as well as commitments from national governments in countries like India.[6]Child growth failures and anemia are the most commonly used indicators of nutritional status in children, especially in low- and middle-income countries.[7]
Sample characteristics Of 139,116 children included in the primary analysis, the overall mean values of height-for-age z-scores (HAZ), weight-for-age zscores (WAZ), weight-for-height z-scores (WHZ), and hemoglobin were also standardized (HZ) were −1.51 (SD, 1.63), −1.52 (SD, 1.21), −0.95 (SD, 1.35), and 0 (SD, 1), respectively
Variance decomposition The total variance estimated from the age- and sex-adjusted model was 2.59 for HAZ, 1.44 for WAZ, 1.83 for WHZ, and 1.04 for HZ
Summary
Child growth failures and anemia are the most commonly used indicators of nutritional status in children, especially in low- and middle-income countries.[7] Child undernutrition—as measured by child anthropometry and hemoglobin level—result from a series of complex interactions between socioeconomic conditions, inadequate dietary intake of key nutrients, and exposure to infectious diseases[1,8,9,10,11] and are known to be detrimental to longterm health, human capital potentials, and economic progress for individuals and societies.[12] Existing frameworks on causes of child malnutrition generally recognize the complex etiology of suboptimum growth with proximate and distal risk factors operating at multiple levels.[1,13] Yet, the independent and joint effects of such risk factors on child undernutrition are often assessed with no clear conceptualization of the inferential targets.[14]. Their independent and joint effects are often assessed with no clear conceptualization of inferential targets
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