Influence of socioeconomic disparities on the nutritional status of Mongolian children under 5 years of age Ganzorig Dorjdagva, Ph.D. HRO Meeting May 28,

Influence of socioeconomic disparities on the nutritional status of Mongolian

children under 5 years of age

Ganzorig Dorjdagva, Ph.D.

HRO MeetingMay 28, 2014

1

• National Center for Health Statistics (NCHS) growth reference is being used for assessment of nutritional status of children since 1978.

• NCHS reference has several limitations and multi ethnical reference was required.

• In 2006 WHO released new standards for assessing the growth and development of children from birth to 5 years of age.

• WHO recommends the use of the WHO standards to assess the growth and development of children worldwide.

New WHO Standards New WHO Standards

• Undernutrition is progressively declining in Asia since 1990.

Stunting was reduced from 40% to 29%; underweight was from

31% to 26%; and wasting was from 21% to 13%. (UNICEF, 2008)

• Underlying causes of malnutrition have been suggested:

o Poverty

o Lack of access to foods

o Conflicts

o Climate change

o Lack of safe drinking water

o Diseases

Global Child Nutrition StatusGlobal Child Nutrition Status

Mongolia

Child Stunting Prevalence in the WorldChild Stunting Prevalence in the World

• Problems include poverty, unemployment, migration, lack of food safety and security.

• Although underweight and wasting are reduced drastically, stunting is still in a high level.

• Exclusive breastfeeding up to 6 months is practiced by majority of women.

• The provision of complementary foods is not adhered to the WHO recommendation.

Problems Related to Nutrition Status of Children in Problems Related to Nutrition Status of Children in MongoliaMongolia

%

6

Stunting in Mongolia (1992-2005) Stunting in Mongolia (1992-2005) by NCHS refby NCHS ref

• Who are vulnerable to child undernutrition in

Mongolia?

• What types of socioeconomic factors are related to

child undernutrition in Mongolia?

• Are there any changes in national nutrition status after

the adoption of the WHO growth standards?

QUESTIONS NEED TO BE ANSWEREDQUESTIONS NEED TO BE ANSWERED

Influence of Socioeconomic Disparities on the Nutritional Status of Mongolian Children under 5

Years of Age

STUDYSTUDY

M

1. To examine the disparities in nutrition by demographic

and socioeconomic factors.

2. To evaluate changes of nutritional status in children

under 5 years of age between 2000 and 2005.

OBJECTIVESOBJECTIVES

Survey name, year RegionsTotal Clusters

Households per Cluster

Households

Total children under 5 years old

Multi-Indicators Clusters Survey 2, 2000

6 300 25 6000 6199


5 253 25 6325 3568


5 420 25 10092 3956

Datasets are available in UNICEF web site: www.childinfo.org

DatasetsDatasets

METHODS

R

Indicator Measure Cut-off

Stunting Height-for-age < - 2SDUnderweight Weight-for-age < - 2SDWasting Weight-for-height < - 2SDOverweight Body mass for index-for-age > 2SD

Nutrition Indicators and DefinitionNutrition Indicators and Definition

Variable Level

Child age <2 years old, ≥2 years oldGender Male, Female*

Areas of residence Rural areas, Urban areas* Mother’s education Less education (≤ 8 years of formal education)

High education* (> 8 years of formal education)

Wealth indexQuintiles (Poorest, Second, Middle, Fourth, Richest*)

* Reference level

Demographic and Socioeconomic VariablesDemographic and Socioeconomic Variables

Calculation of z-scores using WHO growth standard.

Calculation of undernutrition prevalences by

sociodemographic factors.

Chi-square test was used to compare the prevalence of

undernutrition between 2000 and 2005.

Odds ratios of undernutrition by demographic and

socioeconomic factors were estimated with 95%

confidence Interval.

Statistical AnalysisStatistical Analysis

IndicatorMICS2, 2000

MICS3, 2005

MICS3, 2010

P value

Underweight 11.6% 5.3% 3.3 <0.001 Severe underweight 3.9% 1.6% 0.9 <0.001

Wasting 7.1% 2.7% 1.6 <0.001 Severe wasting 3.0% 1.1% 0.7 <0.001

Overweight 14.7% 17.1% 10.9 <0.05 Obese 4.6% 4.9% ? 0.65

Stunting 29.9% 27.5% 15.3 0.07 Severe stunting 12.0% 9.9% 4.7 <0.05

RESULTS

Malnutrition Prevalence in 2000, 2005 and 2010Malnutrition Prevalence in 2000, 2005 and 2010

MICS2, 2000 MICS3, 2005

Stunting Underweight Wasting Stunting Underweight Wasting

Male / Female

1.17 (1.05 - 1.31)

1.22 (1.04 - 1.43)

1.07 (0.88 - 1.31)

1.19 (1.03 - 1.40)

1.00 (0.74 - 1.35)

0.94 (0.62 - 1.43)

Rural / Urban

1.89 (1.68 - 2.12)

1.77 (1.50 - 2.10)

1.48 (1.21 - 1.83)

1.28 (1.10 - 1.49)

1.26 (0.93 - 1.72)

1.06 (0.70 - 1.62)

Less Educ. /High Educ.

1.67 (1.49 - 1.87)

1.65 (1.40 - 1.94)

1.49 (1.22 - 1.83)

1.72 (1.47 - 2.00)

2.01 (1.48 - 2.72)

1.64 (1.08 - 2.50)

Unadjusted odds ratios Unadjusted odds ratios and 95% confidential intervals of and 95% confidential intervals of stunting, underweight and wasting for selected stunting, underweight and wasting for selected sociodemographic factors in children under 5 years of age in sociodemographic factors in children under 5 years of age in 2000 and 20052000 and 2005

2

MICS2, 2000 MICS3, 2005

Stunting Underweight Wasting Stunting Underweight Wasting

Male / Female

1.18 (1.05 – 1.32)

1.22 (1.04 – 1.44)

1.08 (0.88 – 1.32)

1.19 (1.02 – 1.39)

0.99 (0.73 – 1.35)

0.94 (0.62 – 1.44)

Rural / Urban

1.21 (1.03 – 1.41)

1.14 (0.90 – 1.43)

1.15 (0.87 – 1.53)

0.80 (0.65 – 1.00)

0.61 (0.39 – 0.95)

0.62(0.32 – 1.20)

Less Educ. /High Educ.

1.31 (1.16 – 1.49)

1.32 (1.11 – 1.57)

1.29 (1.04 – 1.60)

1.41 (1.80 – 1.68)

1.61 (1.13 – 2.30)

1.61 (0.96 – 2.71)

Adjusted odds ratios* Adjusted odds ratios* and 95% confidential intervals of and 95% confidential intervals of stunting, underweight and wasting for selected stunting, underweight and wasting for selected sociodemographic factors in children under 5 years of age in sociodemographic factors in children under 5 years of age in 2000 and 20052000 and 2005

2

Reduction was observed in rural areas, in severe forms.o Implementation of nutrition program reached to the target

directed to under 2 years old and countryside. o Mass migration from rural areas after 2000. o Other studies showed: Mongolian complementary foods are not

adhered with recommendation. Frequency and amount are insufficient, but contained high calories and low nutrients (Lander R, 2008).

o Micronutrients deficiency – Vit D def 41%, supplementation 15%, 74% of under 3 years old children had Zn deficiency in Mongolia (NNS3, 2004; Lander R, 2010)

Finding 1 – Finding 1 – Nutrition Status was Improved, but Stunting Nutrition Status was Improved, but Stunting was Persistentwas Persistent

DISCUSSION

As for growth patterns, boys in general tend to be taller and heavier than girls. o Other studies showed: Boys are taller in Bangladesh but

shorter in sub-Saharan Africa (Dancer D, 2010; Wamany H, 2007)

oMale gender is more predisposed to affect to undernutrition, morbidity and death (Elsmén E, 2002; Health statistics Mongolia, 2005)

o Sex differential was not shown in NCHS reference, but it was shown in WHO standard in Mongolian cases.

Finding 2 – Finding 2 – Boys were More Stunted than GirlsBoys were More Stunted than Girls

Other studies showed: Children in rural areas in the developing world were almost twice

as likely to be underweight as children in urban areas (Gleland JG,

1988). The rural children were 2 times more affected to stunting and

underweight than urban children in Mongolia (NNS3, 2004). Compared with 2000, in 2005 the area of residence difference did

not show any effects. It might be related to the successful implementation of nutrition programs in countryside, which mainly involved under 2 years old children in Mongolia since 2000. Also it might be related with internal migration after 2000.

Finding 3 – Finding 3 – Residence Difference in NutritionResidence Difference in Nutrition

Similar to other studies in sub-Saharan Africa and Bangladesh (Wamany H, 2004 ; Giashuddin M, 2005).

The Mongolian women’s literacy rate is high (97.8%), but child feeding and caring practice are not adhered with the recommendation. Only 1.6% of 6-11 month old children, 0.9% of 25-59 months old children, and no 12-23 month old children were fed according to the amount and frequency specified in the WHO recommendations. (NNS3, 2004; Lander R, 2008 and 2010).

The lack of economic capacity and child caring and feeding knowledge may reduce health potential of their children.

Finding 4 – Finding 4 – Mother’s Education Level Difference in Mother’s Education Level Difference in NutritionNutrition

The nutritional status in children under five years of age is often associated with measures of poverty. Other studies showed: The children who lived in low income households had 2 times more stunting and 1.7 times more underweight than the children who lived in middle and high income households in Mongolia (NNS3, 2004).The poorest sectors were at least three times as likely to be stunted as those in the richest (Larrea C & Freire W, 2002). Most of poor households placed in rural and peri urban areas. Less educated mothers of this study tend to belong to poor households.

Finding 5 – Finding 5 – Wealth Index Difference in NutritionWealth Index Difference in Nutrition

STUNTINGHAZ< -2SD

MDG, Goal 1, objective 2: 2015 онд 13.0%-д хүргэнэ

UNDERWEIGHTWAZ < -2SD


WASTINGWHZ < -2SD


Documents

Influence of socioeconomic disparities on the nutritional status of Mongolian children under 5 years of age Ganzorig Dorjdagva, Ph.D. HRO Meeting May 28,