Assessment of Undernutrition Among Children in 55 Low- and Middle-Income Countries Using Dietary and Anthropometric Measures
Authors: Markus Heemann, Rockli Kim, Sebastian Vollmer, S. V. Subramanian
Journal: JAMA Network Open (2021)

<h3>Importance</h3> 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. <h3>Objective</h3> 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. <h3>Design, Setting, and Participants</h3> 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. <h3>Exposures</h3> 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<i>z</i>score for stunted growth, muscle wasting, and less than average weight for age. <h3>Main Outcomes and Measures</h3> 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. <h3>Results</h3> 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. <h3>Conclusions and Relevance</h3> 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.