Summary of MSc thesis1
By Abbi Sage
Abbi Sage is a recent MSc graduate in Nutrition for Global Health from the London School of Hygiene and Tropical Medicine. She is now part of the Knowledge Management Team of the Nutrition Division of the World Food Programme.
The author acknowledges her supervisor, Suneetha Kadiyala, and co-supervisor, Helen Harris-Fry, for their joint support.
What we know: A child who is both wasted and stunted has higher associated morbidity and mortality.
What this article adds: This secondary analysis of 2014 MICS data identified socioeconomic and health factors that are associated with concurrent wasting and stunting in children aged 6-59 months in Guinea-Bissau. Six per cent of 6,602 children analysed were wasted (1% severely wasted); 30% were stunted (9% severe); 2.4% of children were both wasted and stunted. Of those stunted, 8.2% were wasted; of those wasted, 40.7% were stunted. Most children (86.2%) did not meet minimum dietary diversity. The largest maternal age group was adolescents (15-19 years) (23%). Concurrent wasting and stunting was more prevalent in boys than girls by 24%. Both observed mosquito net in the house and lack of diarrhoea in the last two weeks were protective of concurrent wasting and stunting. More surprisingly, richer children were 2.27 times more likely to be wasted than the poorest children. The findings reiterate the importance of considering concurrent wasting and stunting in undernourished children for policy and programming.
Wasting and stunting are commonly considered as separate undernutrition conditions in programming and policy worldwide. Recent evidence points to the correlative nature of the two conditions and suggests that a child who is moderately wasted and stunted at the same time is at far higher risk of mortality compared to a severely wasted or stunted child (Khara T, Dolan C, 2014).
With an estimated population of 1.8 million, Guinea-Bissau has a high infant mortality rate at 77.9 per 1,000 births. In 2015, the under-5 mortality rate was even higher at 124 per 1,000 live births (12.4%). Political instability means 70% of the population live in poverty. Food insecurity, seasonal changes in rainfall, poor infant and young child feeding (IYCF) practices, poor water and sanitation, and inadequate health services result in undernutrition being a major public health concern; prevalence of chronic undernutrition is above 25%.
The overall aim of this study was to identify socioeconomic and health factors that are associated with the coexistence of wasting and stunting in children between the age of 6-59 months in Guinea-Bissau. Specific objectives were:
- To characterise patterns of stunting and wasting, with specific focus on the coexistence of stunting and wasting;
- To identify associations between hypothesised socioeconomic and demographic determinants of wasting and stunting separately, and the coexistence of wasting and stunting.
Data from a UNICEF Multiple Indicator Cluster Survey (MICS) published in 2014 were used for this secondary data analysis. Only participants in the MICS that met the eligibility criteria outlined below were included in the analysis. A total of 6,602 children living in 4,016 households and 5,303 mothers were included in the final analysis.
- Children 6-59 months of age with data on both weight-for-height z score (WHZ) and height-for-age (HAZ) and the mothers/caregivers of those infants.
- Women aged 15-49 years in original survey who did not have children 0-5 years of age;
- Households without children under five years of age;
- Anthropometry outliers using the World Health Organisation (WHO) cut-off criteria of >5.00 & <-6.00 z-scores;
- Infants 0-6 months of age (due to programmatic and biological differences in dealing with wasting or stunting in infants aged 0-6 months compared to children aged 6-59 months).
Using the UNICEF conceptual framework of undernutrition, indicators from the original survey were used as proxy measures for more commonly used indicators, based on prior literature. In this study, the immediate predictors were considered at the individual level of the child, while the underlying and basic predictors are at the maternal and household level (see Figure 1).
*Female Genital Mutilation (FGM) was included in the model due to Guinea-Bissau’s high rate of this practice, used as a proxy indicator for women’s empowerment.
Univariate, multinomial logistic regression was initially used to investigate crude relationships between covariates and wasting; stunting; and wasting and stunting combined, compared to not wasted or not stunted children. Variables in the univariate analysis with a small sample size due to missing values were not included in the multivariable regression. The multivariable regression results were deemed statistically significant if covariates produced a p-value of ≤0.05. All analyses accounted for the clustered sample design.
Of 6,602 children, 3,257 were girls (49.3%). The mean age of all children was 32 months (95% CI 31.4, 32.3); 63.3% (4,862) of the children were from a rural setting.
For children aged 6-23 months, 86.2% did not meet minimum dietary diversity, with the median being two food groups (IQR 1.5, 2.5). Of note, 43.1% of information on child dietary diversity was missing. A total of 12.6% of children had diarrhoea in the previous two weeks; children aged 6-11 months had the highest prevalence of diarrhoea at 25.4%.
The median age of mother/caregivers was 27 years (IQR 26.5, 27.5); the largest group of mothers were adolescents themselves (23%), aged 15-19 years old. Approximately 60% of mothers had no formal education. Most (92.2%) of women claimed to have had antenatal care during pregnancy, however 67.7% of the data were missing.
Most (97%) households had an observed mosquito net. Once disaggregated by anthropometric deficit, almost 10% of wasted and stunted children did not have a mosquito net in their house, followed by 5% of wasted children compared to 3% of not stunted or wasted children and 2% of stunted children. Roughly half of households were Muslim and approximately one third of mothers had undergone genital mutilation. The poorest wealth index had the highest percentage of female genital mutilation (29%).
Six per cent of children were wasted, of whom 1% were severely wasted. Among all the predictors tested in the multivariate model, a child whose mother had undergone FGM had a reduced risk of wasting by 31% (p-value 0.05). Taking a closer look at this result, the confidence interval crosses one (0.47, 1.01), reducing the certainty of the significance which could be a result of the arbitrary p-value cut-off.
Surprisingly, there were more wasted children who were wealthy compared to the poorest in the sample population being studied. Children with a richer wealth index were 2.27 times more likely to be wasted than children with the poorest wealth index (p-value 0.006). One explanation for this association may be that more children were wasted in urban areas than rural areas (4.2% and 3.2% respectively). It may not be the case that a higher wealth index predicts wasting but that, in this population, children were more likely to be wasted due to the higher percentage of wasted children living in urban areas, where wealth index scores were generally higher. The urban capital, Sector Autónomo de Bissau (SAB), had the highest percentage of wasting compared to all other regions. Future research is needed into the current state of children in urban settings in Guinea-Bissau, particularly SAB, to understand the factors at play with this association.
Approximately 30% of children were stunted, with severe stunting at 9%. In the multivariate model all age groups had a strongly significant higher risk of being stunted compared to 6-11 month old children (p-value <0.001). There was weak evidence that children who had an educated mother at secondary level were almost 30% less at risk of being stunted than those who had an uneducated mother (p-value 0.045). Children from the richer and richest wealth index were 46% and 63% respectively less at risk of being stunted than children from the poorest wealth index (p-values <0.001).
Wasting and stunting
Only 2.4% of children aged 6-59 months were both wasted and stunted at the time of the survey; however, of those stunted, 8.2% were wasted and of those who were wasted, 40.7% were stunted. No wasting, no stunting, and wasting and stunting individually were distributed equally across girls and boys. However, boys were 24% more concurrently wasted and stunted than girls.
In the multivariate analysis, children who had diarrhoea in the last two weeks were 75% more at risk of being both wasted and stunted than those who did not, relative to children who were neither wasted or stunted (p-value 0.022). There was strong evidence that having a mosquito net in the household decreased a child’s risk of being both wasted and stunted by 78% compared to not having a mosquito net (p-value 0.003).
Due to the small sample size of the psychosocial stimulation predictor, a separate multivariate regression adjusting for sex, child age, mother age and wealth index was created. There was weak evidence for a protective association between psychosocial stimulation and wasting and stunting (N=2,744). For every additional person to engage in cognitively engaging activities with the child, the child had a 15% lower risk of being concurrently wasted and stunted, relative to a not stunted or wasted child (p-value 0.043).
This study has highlighted that associations that are insignificant for wasting and stunting individually become significant once wasting and stunting coexists in a child in Guinea-Bissau. In particular, observed mosquito net in the house and lack of diarrhoea in the last two weeks were both protective of concurrent wasting and stunting.
Approximately 30% of children were stunted (WHO high public health concern), while 6% were wasted (WHO medium public health concern). Due to the cross-sectional nature of the data, the prevalence of wasting seen here may not reflect the true prevalence of wasting in under-fives. Another limitation of this analysis is missing data, limiting the ability to test predictors such as dietary diversity and antenatal care.
The findings reiterate the importance of considering concurrent wasting and stunting when considering programming and policy to address undernutrition in Guinea-Bissau.
For more information, contact: Abbi Sage, email@example.com
1Sage, A. (2016). Secondary Data Analysis on the Coexistence of Wasting and Stunting in Children Under-5 in Guinea-Bissau using MICS 2014 data. MSc Nutrition for Global Health thesis, London School of Hygiene and Tropical Medicine
Khara T, Dolan C, 2014 Technical Briefing Paper: Associations between Wasting and Stunting, policy, programming and research implications. Emergency Nutrition Network: Emergency Nutrition Network, 2014.
More like this
FEX: Relationships between wasting and stunting and their concurrent occurrence in Ghanaian pre-school children
Summary of research* Location: Ghana. What we know: Wasting is a short-term health issue, but repeated episodes may lead to stunting (long-term or chronic malnutrition). This...
FEX: Children concurrently wasted and stunted: A meta-analysis of prevalence data of children 6–59 months from 84 countries
Summary of research By Tanya Khara, Martha Mwangome, Moses Ngari and Carmel Dolan Tanya Khara and Carmel Dolan are ENN Technical Directors. They coordinate the ENN...
FEX: Nutritional status of children and pregnant and lactating women in relief camps in post-tsunami Sri Lanka
Summary of published research 1 The post-tsunami survey reported below describes a decline in nutrition and health status amongst women and children, and makes...
Summary of article1 Location: Global What we know: The relationship between wasting and stunting is under researched and poorly understood. What this article adds: A...
Summary of research1 Location: Urban slum, Bangladesh What we know already: Both severe acute malnutrition (wasting) and severe chronic malnutrition (stunting) are prevalent...
Summary of research* Location: Ethiopia What we know: The prevalence of stunting and wasting in Ethiopia has fallen but remains a considerable burden. Effective nutrition...
A team of researchers recently investigated the effect of an SFP on malnourished children in Guinea-Bissau who were returning to their homes after having been displaced within...
FEX: Stunting and wasting in children under two years old in a semi-nomadic pastoralist population in Kenya
By Amelia Reese-Masterson, Masumi Maehara and Mark Murage Gathii Amelia Reese-Masterson is Research Advisor in the Nutrition, Food Security and Livelihoods Unit at...
Summary of review1 This summary was prepared by Tanya Khara, an independent consultant engaged by the ENN on this review. The review was made possible by the generous support...
Summary of research1 Location: Ethiopia What we know: Rapid economic growth in developing countries has had a mixed effect on human development; the impact on reducing...
If a child is growing normally following the growth trajectory based on a growth chart, can we say that the child is not wasted/stunted? I know that if a child is low...
What is the ratio between severe to moderate wasting and severe to moderate stunting that can be expected in a given population? Any reference? Do you mean the ratio of the...
Donor: OFDA and Irish Aid Collaborators: Technical Interest Group ENN project lead: Carmel Dolan Timeframe: 2014 - ongoing Background While wasting and stunting share...
Summary of published research1 Location: Africa, Asia, Latin America What we know already: Wasting and stunting are respectively short term and longer term conditions of...
Research snapshot1 The Maya people are descended from the indigenous inhabitants of southern Mexico, Guatemala and adjacent regions of Central America. In Guatemala, 50% of...
James P, Sadler K, Wondafrash M, Argaw A, Luo H, Geleta B, et al. (2016) Children with Moderate Acute Malnutrition with No Access to Supplementary Feeding Programmes Experience...
Summary of published paper1 Well nourished breastfeeding child with mother A recent study set out to assess the impact of prolonged breast-feeding on internally displaced...
Summary of research1 This research contributes to the evidence base regarding which anthropometric indicators identify malnourished sick children most at risk of death. Low...
Summary of research* Location: Global. What we know: There is global momentum to bring down levels of undernutrition. Wasting and stunting frequently co-exist, but are often...
Resource: Children concurrently wasted and stunted: A meta-analysis of prevalence data of children 6 – 59 months from 84 countries
Children can be stunted and wasted at the same time. Having both deficits greatly elevates risk of mortality. The analysis aimed to estimate the prevalence and burden of...
Reference this page
Abbi Sage (2017). Predicting coexistence of wasting and stunting in Guinea-Bissau: A secondary data analysis. Field Exchange 54, February 2017. p40. www.ennonline.net/fex/54/predictingwastingstuntinggbissau