nutritional status of preschool children in northern vietnam

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Nutritional status of preschoolchildren in Northern VietnamSuzanne Shoff a , Joanne Csete b , Judith Ladinsky c & HoangThuy Nguyen da Department of Nutritional Sciences , University ofWisconsin‐Madison , 1415 Linden Drive, Madison, WI, 53706,USAb Department of Nutritional Sciences , University ofWisconsin‐Madison , Madison, WIc Department of Preventive Medicine, International Health ,University of Wisconsin‐Madison , Madisond Director, National Institute for Hygiene and Epidemiology ,Hanoi, VietnamPublished online: 31 Aug 2010.

To cite this article: Suzanne Shoff , Joanne Csete , Judith Ladinsky & Hoang Thuy Nguyen(1993) Nutritional status of preschool children in Northern Vietnam, Ecology of Food andNutrition, 29:3, 235-255, DOI: 10.1080/03670244.1993.9991308

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Ecology of Food and Nutrition, Vol. 29. pp. 235-255Reprints available djrccily from the publisherPhotocopying permitted by license only

© 1993 Gordon and Breach Science Publishers S.A.

Printed in Malaysia

NUTRITIONAL STATUS OF PRESCHOOLCHILDREN IN NORTHERN VIETNAM

SUZANNE SHOFF and JOANNE CSETE

Department of Nutritional Sciences, University of Wisconsin-Madison, MadisonWI

JUDITH LADINSKY

Department of Preventive Medicine, International Health, University ofWisconsin-Madison

HOANG THUY NGUYEN

Director, National Institute for Hygiene and Epidemiology, Hanoi, Vietnam

(Received April 13, 1992; in final form August 17, 1992)

After three decades of war and social turmoil in Vietnam, infant mortality is high and related healthand nutritional problems are widespread. Studies which have investigated health or nutrition char-acteristics of the Vietnamese population are scarce. This paper offers the first multivariate analysisof nutritional status of Vietnamese children in recent history. The relationship between a number ofhousehold-level variables and nutritional outcomes of preschool children surveyed over two years innorthern Vietnam is investigated. During four survey rounds, as many as 82% and 80% of childrenunder 72 months fell below a Z-score of - 2 for weight/age and height/age, respectively. A maximumof 44% and 57% of children fell below a Z-score of - 2 for growth velocity (weight and stature,respectively). Positive predictors of attained growth were hemoglobin level and sex (males havingbetter nutritional status). Household size, weaning practices and household illness were not associatedwith attained growth.

KEY WORDS: Vietnam, nutritional status, children, growth, weaning

INTRODUCTION

The Socialist Republic of Vietnam, still recovering from three decades of war,has been handicapped by limited resources for health and nutrition services(Fforde and Vylder, 1988; Tanumidjaja, 1982). The health situation, althoughslowly improving, remains precarious. In 1989, the infant mortality rate (underone year) and the under-five mortality rate were estimated at 61 deaths per 1000live births and 84 deaths per 1000 live births, respectively (UNICEF, 1991). Be-tween 1982 and 1988, the percent of infants with low birthweight (under 2500grams) was 18% of live births (UNICEF, 1991). Since Vietnam is generally lackingin resources for conducting and managing large-scale surveys, these figures maybe unreliable and may not reflect the situation of large segments of the populationthat have serious food problems (Fforde and de Vylder, 1988).

Address correspondence to: Ms. Suzanne Shoff, M.S., Department of Nutritional Sciences. Uni-versity of Wisconsin-Madison. 1415 Linden Drive. Madison. WI USA 53706

235

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236 S. SHOFF, J. CSETE, J. LADINSKY AND H. T. NGUYEN

Studies that have investigated the health/nutrition characteristics of the Vi-etnamese population are scarce and limited to a few descriptive statistics (Nguyen,Pham and Weitzel, 1990; Vu and Han, 1984; UNICEF, 1990). By all accounts,the Vietnamese preschool population is undernourished, yet the household-levelfactors related to this problem have not been examined. The need for reliablenutrition research in Vietnam is unquestionable, particularly on problems of vul-nerable groups such as young children and women in the reproductive years. Asattempts are being made to re-establish relations with Western countries afteryears of economic isolation (Far Eastern Economic Review, 1991), there is a greatneed for a better understanding of the basic-needs situation of the people andfor baseline information for potential donor agencies.

This paper offers the first multivariate analysis of nutritional status of Viet-namese children in recent history. Although the nutritional data examined herewere collected as part of a larger study that did not have nutritional status ofchildren as a central focus (see methods below), the data allowed for the testingof a number of hypotheses about nutritional outcome in a multivariate model. Inparticular, in this analysis we explored (1) the relationship between weaningpractices and nutritional outcome (weight for age, height for age, weight forheight, longitudinal growth and hemoglobin status) and (2) the relationship be-tween child's age and sex and nutritional outcome. Additionally, we examinedgrowth patterns of children under five years over a two-year period.

METHODS

Location and Sample Population

The data reported here were collected through a household survey conducted in1985-87 in six northern provinces (Ha Nim Ning, Ha Son Binh, Hai Hung, ThaiBing, Haiphong and Hanoi) as part of the evaluation of a primary health care(PHC) intervention. This intervention included (1) comprehensive training ofphysicians at the provincial level who subsequently trained village health workersand (2) supplying basic medical equipment and Pharmaceuticals. The entire proj-ect involved gathering information on the health status of the population, un-derstanding the role of the VHW, and the evaluation of the appropriate supplyof medical supplies and equipment. Within each province, the survey coveredtwo villages that were assumed to be comparable in socioeconomic status, pop-ulation density and ethnicity. Later it was recognized that the control villageswere somewhat better off economically. In the analyses reported here, the statusof a village as control or experimental is accounted for, but the outcome of interestis nutritional status (as represented by the indicators mentioned above) of childrenin all villages. Each of the twelve villages had 7-18 "production brigades" com-posed of 80-100 households each. The sampling frame was a complete list ofhouseholds in the brigade; four households were randomly selected for the surveyusing a random numbers table. If a village had more than ten production brigades,every second or third one was chosen. Thus, 184 households (from 46 productionbrigades) formed the experimental group and 196 (from 49 production brigades)formed the control group for the initial survey round. A total of 181 householdsin the study had at least one child under three years at the initial survey (olderchildren were not included at baseline). For each subsequent survey round.

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NUTRITION OF VIETNAMESE PRESCHOOLERS 237

weight, height and hemoglobin data were collected for up to 273 children underthe age of six years.

An adult respondent, usually the mother of the children, was interviewed ineach household in the sample to determine household size, age of infant weaningand introduction of first solid food, and whether any household member sufferedfrom a month-long cough. The cough question was meant to approximate prev-alence of chronic respiratory infection. Additionally, a question was asked todetermine when the most recent episode of diarrhea (three or more watery stoolsin one day) for any child in the household occurred (today, one week ago, twoweeks ago, less than one month ago, or never). Nearly 50% of the respondentsdid not answer this question throughout the survey; thus this variable was notincluded. Four survey rounds were conducted by National Institute of Hygieneand Epidemiology (Hanoi) evaluators. Baseline data were collected during June1985 with follow-up surveys in December 1985, June 1986, and June 1987. Therewere 129 children who had weight and height measurements taken for all surveyrounds.

Procedures

Anthropometry and hemoglobin. As part of the baseline survey, children underthree years of age were weighed (to the nearest 0.1 kilogram) and measured forsupine length (under two years, to the nearest centimeter) or height (two yearsor older, to the nearest centimeter) at the time of the interview according tostandard procedures (Jelliffe, 1966). Weight and height measurements were takenonce. Repeat visits were made in an attempt to measure each child. These attemptswere not always successful primarily due to a child being in another area visitinga relative and secondarily to refusals for measurement due to illness or perceivedrisks associated with taking the measurement. Age was determined by asking themother the birth date of the child. If date of birth was not known, the motherwas asked to give the age (in months) of the child. Actual sample sizes for eachmeasurement are shown in Table IX.

For hemoglobin measurements, blood from a finger prick was immediatelyprocessed and placed in a hemoglobinometer (Evatt et al., 1983) to determinehemoglobin concentration. Hemoglobin is expressed as grams/deciliter.

Statistical analysis of survey data. Three anthropometric indicators were con-structed: weight for age (W/A), height for age (H/A), and weight for height (W7H). These were compared to the U.S. National Center for Health Statistics(NCHS) growth tables (Hamill et al., 1977) and expressed as standard deviationscores (Z-scores) using public-domain software of the U.S. Centers for DiseaseControl (Jordan, 1987). No single classification system has been developed forZ-scores, but accepted approximations based on other systems are: normal(> —1), mildly malnourished ( — 1 to —1.99), moderately malnourished ( — 2 to-2.99), and severely malnourished ( s - 3 ) (Waterlow et al., 1977).

Incremental growth was standardized by comparing weight and height velocities(growth between two time points) to reference growth velocities reported intabular form by Baumgartner, Roche and Himes (1986) and expressed as Z-scores. Expressing growth this way takes into account normal differences in growthrate experienced at different ages.

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Statistical procedures were performed on a microcomputer using SPSS/PC+.Stepwise regression analysis was used to examine the relationship between severalhousehold-level variables and nutritional outcome (Z-score of W/A, H/A, W/H, and standardized weight and height increments) for each survey round. Tomaximize sample size and normalize outcome variable distributions, dependentvariable means (of four rounds) were used in regression analyses and are reported.Independent variables (hemoglobin, age received first solid food, age stoppedbreastfeeding and household size) were also averaged for each case across surveyrounds and included as such in the regression analyses. The mean response toweaning questions was used since no differences in results were observed whenthe response from the first time the question was asked was used.

Residual analysis, used as others have described (Esrey, Casella and Habicht,1990; Doan and Bisharat, 1990; Launer, Habicht and Kardjat, 1990; Johnston,1931), was performed to examine growth (weight and height) between each surveyround. This procedure resulted in six two-stage regressions (three for weight,three for height). Residuals were generated from a first-stage regression (weightor height,,imc 2) = weight or height(Iimc n + age) and were used as the dependentvariable in the second stage of analysis where the effect of several household-level variables was examined. Previous weight or height and age are highly cor-related with final growth measurements. This procedure enables the examinationof growth not attributable to age, previous weight or height, and other deter-minants of child growth which are contained in the initial growth measurement.Means of independent variables were not used here.

For'the regression analyses, means of independent continuous variables andmedians of non-continuous variables were substituted for missing values (Cohenand Cohen, 1975). The percentage of cases with missing information for anyindependent variables ranged between 1% (age first received solid food) and 39%(presence of month-long cough). These cases tended to have better nutritionalstatus, were younger, and came from smaller families. The number of cases withmeasurements for outcome variables determined the sample size for a particularanalysis.

RESULTS

Descriptive Statistics

Overall distribution of attained Z-scores. Figures 1-3 show normalized Z-scoredistributions of W/A, H/A, and W/H (all averaged across rounds) for the samplepopulation and the NCHS reference population. Compared to the reference pop-ulation, the sample W/A and H/A values are dramatically lower. W/H is alsolower, but the decreased prevalence of low W/H reflects a high prevalence oflow H/A (stunting). Tables I-IV show the percentage of children from each surveyround falling within specified Z-score ranges. There was a high prevalence of lowW/A and low H/A throughout the four survey rounds, particularly within olderage groups (up to 82% and 80%, respectively, as defined by a Z-score less than- 2 ) . Low W/H was less prevalent (up to 29%). Those who were not measuredtended to be part of smaller families (four versus six members) and to reside inmore highly populated provinces (particularly Hai Hung and Haiphong). Im-pairment of growth velocity, expressed as Z-scores of weight and height incre-

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HI0.

40-i

3 0 -

2 0 -

10-

reference population (NCHS)

sample population, mean W/A

- 4 - 3 - 2 - 1 0 1

Z-SCORE

FIGURE 1. Normalized population distributions: weight for age.

ments, was less widespread. The percent of children with Z-scores less than - 2was less than that for attained growth: up to 44% for the weight increment and57% for the height increment (Tables V-VII). This suggests that although manychildren had depressed weights and heights, some were growing at near normalrates.

40 -i

ID0 .

3 0 -

2 0 -

10 -


sample population, mean H/A

- 5 - 4 - 3 - 2 - 1 0

Z-SCORE

FIGURE 2. Normalized population distributions: height for age.

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40 -i

30 -

2 0 -

10-

-3


sample population, mean W/H

-2 -1 0

Z-SCORE

FIGURE 3. Normalized population distributions: weight for height.

TABLE IAnthropometric indicators of nutritional status expressed as Z-scores. Percent children falling within

specified Z-score ranges'.

AGE(months)

weight/age0-12

13-2425-36

height/age0-12

13-2425-36

weight/height0-12

13-2425-36

NO.CHILDREN

567270

567575

547269

> - l%

40109

33114

746167

Z-SCORE RANGES(from survey round 1. 6/85)

- 1 to -1.99%

341927

341317

132220

- 2 to -2.99%

134044

202335

71410

s - 3%

13 .3120

135344

633

'Accepted approximations for the classification of Z-scores are: normal ( > - 1), mildly malnour-ished ( - 1 to - 1.99). moderately malnourished ( - 2 to -2.99). and severely malnourished ( s - 3 ) .

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TABLE 11Anthropometric indicators of nutritional status expressed as Z-scores. Percent children lulling within


AGE(months)

weightlage0-12

13-2425-3637-48

height/age0-12

13-2425-3637-48

weight/height0-12

13-2425-3637-48

NO.CHILDREN

51667051

49656750

49656750

> - l%

56221712

451176

70777359

Z-SCORE RANGES(from survey round 2. 12/85)

- 1 to —1.99-%

16363031

16231314

12152135

- 2 to -2.99%

16313645

19283729

12556

£ - 3%

12111712

20384351

631

—

'Accepted approximations for the classification of Z-scores are: normal ( > - 1), mildly malnour-ished ( — 1 to - 1.99), moderately malnourished ( — 2 to —2.99), and severely malnourished ( £ - 3 ) .

TABLE IIIAnthropometric indicators of nutritional status expressed as Z-scores. Percent children falling within


AGE(months)

weightlage0-12

13-2425-3637-4849 +

height/age0-12

13-2425-3637-4849 +

weight/height0-12

13-2425-3637-4849 +

NO.CHILDREN

5260616022

4959616022

4759616022

> - l%

40171339

24872

14

7956645773

Z-SCORE RANGES(from survey round 3, 6/86)

- 1 to -1.99%

•332026379

361528189

1325253322

- 2 to -2.99%

1945484273

2241362727

21711105

£ - 3%

81813189

1836295350

62

———

'Accepted approximations for the classification of Z-scores are: normal ( > - 1), mildly malnour-ished ( - 1 to - 1.99), moderately malnourished ( - 2 to -2.99). and severely malnourished ( £ - 3 ) .

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TABLE IVAnthropometric indicators of nutritional status expressed as Z-scores. Percent children falling within


AGE(months)

weight/age0-12

13-2425-3637-4849 +

height/age0-12

13-2425-3637-4849 +

weight/height0-12

13-2425-3637-4849 +

NO.CHILDREN

2548555886

2448535885

2448535885

> - l%

321513101

50151198

4642554338

Z-SCORE RANGES(from survey round 4, 6/87)

- 1 to -1.99%

3221222629

3814322512

2524234138

- 2 to -2.99%

2833475249

829383846

2115181417

s - 3%

831181221

442192834

819427

'Accepted approximations for the classification of Z-scores are: normal ( > - l ) , mildly malnour-ished ( - 1 to -1.99), moderately malnourished ( - 2 to -2.99), and severely malnourished ( s - 3 ) .

TABLE VIncremental (longitudinal) growth expressed as Z-scores. Percent children falling within specified Z-

score ranges.

AGE (at round2. months)

weight increment0-12

13-2425-3637-48

height increment0-12

13-2425-3637-48

NO.CHILDREN

19545742

19546244

> - 2%

73788269

68576075

Z-SCORE RANGES(growth between rounds 1 and 2)

- 2 to -2.99%

11111314

10307

< - 3%

16115

17

32331018

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TABLE VIIncremental (longitudinal) growth expressed as Z-scores. Percent children falling within specified Z-

score ranges.


weight increment0-12

13-2425-3637-4849 +

height increment0-12

13-2425-3637-4849 +

NO.CHILDREN

-2352545020

2352545020

> - 2%

5664656465

4358917055


- 2 to -2.99%

2217221615

22• 1 5

41620

£ - 3%

2219132020

35275

1425

Anthropometric Z-scores by round and age group. Figures 4-6 show mean an-thropometric Z-scores (W/A, H/A and W/H) over the course of the survey byage groups. For children under 12 months at round one, there was a continualdecline in W/A, H/A and W/H for the following 12 months (two survey rounds).Beyond this age (12 months) and time period (two rounds), there was morevariability in the patterns of the three anthropometric indicators. For children

TABLE VIIIncremental (longitudinal) growth expressed as Z-scores. Percent children falling within specified Z-

score ranges.


weight increment13-2425-3637-4849 +

height increment13-2425-3637-4849 +

NO.CHILDREN

38525779

38525779

> - 2. %

89908676

82928886


- 2 to -2.99%

68

1015

86

106

%

5249

10228

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O-i

-1 -

UJ

88

- 2 -

•m

6/85 12/85 6/86

1 -6 months

7-12 months

13-18 months

19-24 months

25 - 30 months

31 - 36 months

6/87

FIGURE 4. Changes during the survey period of mean VWA Z-scores for six age groups (allchildren included). Legend indicates age at round 1: age increases by amount of time equal to theamount between survey rounds.

-1.5-

LU

o

-2.5-

-3.5

*•—

1 -6 months

7-12monlhs

13-18 months

19 - 24 months

25 - 30 months

31 - 36 months

6/85 12/85 6/86 6/87

FIGURE 5. Changes during the survey period of mean H/A Z-scores for six age groups (all childrenincluded). Legend indicates age at round 1; age increases by amount of time equal to the amountbetween survey rounds.

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0.5-

UJ

5Ow

-0.5-

-1.56/85 12/8S 6/86

1 - 6 months

7-12 months

13-18 months

19-24 months

25-30monlhs

3t-36 months

6/87

FIGURE 6. Changes during the survey period of mean W/H Z-scores for six age groups (allchildren included). Legend indicates age at round 1; age increases by amount of time equal to theamount between survey rounds.

over 12 months at round one there was an improvement in W/A by round two,but thereafter there was a decline. By round four, the mean W/A Z-score for allage groups was about - 2 or below. For H/A, after round three all age groupsexhibited improvement in mean Z-score. Despite improved H/A by round four,mean Z-scores hover around -2 .5 . W/H shows a general decline for all agegroups after round two. Similar patterns of attained growth over the survey periodwere observed for children who participated in all four rounds (data not shown).

Hemoglobin by round and age group. Hemoglobin (hgb) values by age groupat each survey round are shown in Table VIII. Older children tend to have betterhgb levels. Hgb levels also appear to improve over the course of the survey.

Regression Analyses

Results of regression analyses are shown in Tables XI and XII. Mean values forvariables used in regression equations are shown in Table IX. Non-continuousvariables and the coding scheme used are given in Table X.

Mean age is negatively associated with mean W/A and H/A Z-scores (olderchildren having poorer W/A and H/A status). This relationship is also foundwhen W/A and H/A are examined by survey round (data not shown). However,mean age is positively associated with mean incremental growth and also withmean hgb levels.

A positive association is observed between mean hgb levels and attained growthvariables. A negative relationship is observed with mean weight increment Z-

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TABLE VIIIHemoglobin (g/dl) of children by age.1

AGE(months)

0-12

13-24

25-36

37-48

49 +

ROUND 1(6/85)

8.8(1.5.41)

9.8(1.5. 73)

10.5(1.5.61)

HEMOGLOBIN

ROUND 2(12/85)

9.8(1.4.31)

10.1(1.4.60)

10.8(1.4.65)

11.0(1.1.43)

(g/dl)

ROUND 3(6/86)

9.6(1.5.24)

10.2(1.6. 48)

10.9(1.7. 56)

11.2(2.0. 56)

11.1(1.5. 18)

ROUND 4(6/87)

11.6(1.0.6)

10.8(1.7.24)

11.9(1.7.44)

11.7(1.7.54)

11.9(1.7.79)

'hemoglobin (std. deviation. N)

score. To ascertain the influence of outliers on this association, the analysis wasrun excluding outliers. An outlier was defined as cases with values greater thanor equal to 1.5 times the upper boundary of the 75th percentile or the lowerboundary of the 25th percentile. The negative association remained (data notshown).

The age at which a child stopped breastfeeding was nearly significantly relatedto mean weight increment (negatively) and mean hgb (positively). Morbidity, asmeasured by whether or not anyone in a household experienced a month-longcough, was positively associated (an answer of "no") with mean weight incrementZ-score.

Residual analysis (Table XII), by taking age and previous growth into account,reveals several different associations: (1) female sex was associated with poornutritional outcome (significant for all except height, round 2 and weight, round3), (2) a larger household size was positively related to height (round 2), (3) agreater hgb level was positively associated with height (round 3), but negativelyassociated with weight (round 3), and (4) weaning variables showed no significantassociations. To explore the negative association between hgb and residuals ofweight (round three), outliers were excluded from the analysis. The associationremained significant (data not shown). This result is consistent with the negativerelationship observed between mean hgb and mean weight increment Z-score.

DISCUSSION

The analysis presented here is limited by a data set that is flawed. The primarylimitations of the data set are missing values for certain variables and informationon a narrow range of household-level variables. Interpretation of the results shouldbe made with caution. Despite these weaknesses, it is clear that this is a populationof young children with severe nutritional problems and thus at risk for a numberof important health problems and delayed cognitive development (Grantham-

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TABLE IXMean values for several outcome and independent variables

VARIABLESMEAN (SD)*

N VARIABLESMEAN (SD)

N zH

>

men

m3m00

£OOmGO

AGE STOPPED BREASTFEEDING (months)

AGE FIRST RECEIVED SOLID FOOD(months)MEAN HOUSEHOLD SIZE

MEAN AGE (months)

AGE' • (round 1)

AGE (round 2)

AGE (round 3)

AGE (round 4)

MEAN WEIGHT/AGE Z-SCORE

MEAN HEIGHT/AGE Z-SCORE

MEAN WEIGHT/HEIGHT Z-SCORE

15(4)2534(2)2966(2)213

25(14)327

21(11)218

24 (13)251

28(15)275

37 (18)308

-1.94(0.98)310

-2.28(1.50)309

-0.68(1.07)307

MEAN HGB

MEAN WEIGHT INCREMENT Z-SCORE

MEAN HEIGHT INCREMENT Z-SCORE

WEIGHT* (round 1)

WEIGHT (round 2)

WEIGHT (round 3)

WEIGHT (round 4)

HEIGHT** (round 1)

HEIGHT (round 2)

HEIGHT (round 3)

HEIGHT (round 4)

10.7 (1.2)239

-0.82 (1.21)254

-0.31 (1.82)257

8.6 (2.3)199

9.5 (2.4)238

9.6 (2.6)255

10.7 (2.5)273

73 (9)207

76(10)231

78 (10)251

85(11)269

•(SD) = standard deviation *'months 'kilograms **centimeters

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Sex

Experimental status

Presence of month-long cough inhousehold

female .malecontrol villagesexperimental villagesyes

no


TABLE XCoding scheme for non-continuous variables

VARIABLES CODING SCHEME CHARACTERISTICS ASSIGNED VALUE

= 0—- j

= 0= 1= 0

= 1

McGregor et al., 1991; Williams and Williams, 1989). It is striking to find so muchundernutrition in a non-famine, non-clinic-based study population.

Descriptive Statistics

Weight and height. This population is characterized by a high prevalence ofheight for age deficiency and a high prevalence of suppression of the growthprocess as measured by incremental growth. Acute malnutrition as measured byW/H is less prevalent, but this observation occurs in a stunted population. Onaverage, 29% of children under twelve months and 63% of children over twelvemonths were moderately malnourished (W/A Z-score less than - 2 , Tables I-IV). The percentage of stunting (H/A Z-score less than - 2, Tables I-IV) amongchildren under and over twelve months averages 31% and 73%, respectively.These are alarming percentages of undernutrition. Similar rates of malnutritionhave been observed among children from northern Vietnam (Nguyen, Pham andWeitzel, 1990) and Bangladesh (Briend et al., 1989). Similar mean Z-scores forW/A and H/A were observed among children from India (Rao and Kanade,1988) and Yemen (Jumaan et al., 1989). A lower prevalence of undernutritionhas been observed among children from Sri Lanka (Cousens, Mertens and Fer-nando, 1990), Jamaica (Powell and Grantham-McGregor, 1985), Haiti (Smith etal., 1983), and the Philippines (Popkin and Yamamoto, 1985).

Two recent studies have reported weights and heights of Vietnamese children;these are the only studies these authors are aware of that are available to Westernreaders. Vu and Han (1984) reported heights and weights of children under threeyears of age selected from child-care facilities (creches) throughout Vietnam dur-ing 1976-1980. Nguyen et al. (1990) reported weights and heights of childrenunder five years of age from two communes in Thai Binh (a northern province).Children from this study were smaller than those reported by Vu and Han (8.4%smaller in height) and larger than those reported by Nguyen et al. (6.7% heavier).Collectively, these Vietnamese children are shorter and weigh less than childrenfrom other Southeast Asian countries (Eveleth and Tanner, 1976) and China(Zhang and Huang, 1988). Although the argument could be made that thesedifferences are due to genetic factors, we think that the high prevalence of un-derweight and short stature are primarily due to adverse environmental circum-stances. Differences in attained growth status among different ethnic groups and

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TABLE XIRegression coefficients and 95% confidence intervals (in parentheses) from multiple regression analyses of several nutritional status indicators (mean of

4 survey rounds). All variables entered into model are reported.1

INDEPENDENTVARIABLE

interceptAGE

HEMOGLOBIN(u/dl)

AGE FIRST RECEIVEDSOLID FOOD

COUGH (round 1.0 =Y. 1 = N)EXPTL GROUP (0 =C.1 = E)adjusted R-'sic. of F statisticN

MEAN W/AZ-SCORE

-2.394-0.019***

(-0.027. -0.012)0.014*

(0.003. 0.200)

-0.273*(-0.482, -0.063)

0.0900.000

310

MEAN H/AZ-SCORE

-2.814-0.039*"

(-0.051. -0.028)0.164*

(0.018. 0.311)

-0.431**(-0.742. -0.120)

0.1460.000

309

OUTCOME VARIABLES

MEAN WEIGHTINCREMENT

Z-SCORE

1.0970.015*

(0.003. 0.027)-0.231**

(-0.368. -0.094)

0.394*(0.019. 0.769)

0.0540.001

254

MEAN HEIGHTINCREMENT

Z-SCORE

-1.5830.046* "

(0.029. 0.063)

0.0980.000

257

MEANHEMOGLOBIN

(g/dl)

9.6010.026'" '

(0.014. 0.039)NA

0.088°(0.011.0.166)

0.0840.000

239

NU

T

73Hozo<ffl

>

rnm"073rn2(~\\J

oSm73on

'Variables included for possible entry into model but which did not meet entry requirements are: sex. household size, age at which breast-feedingstopped and presence of month-long cough from survey rounds 2-4. No variables were entered for mean weight/height.

0.05 *p £ 0.01 : 0.001

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TABLE XIIRegression coefficients and 95% confidence intervals (in parentheses) from residual analysis of several nutritional status indicators. All variables entered

into model are reported.1

'Variables included for possible entry into model but which did not meet entry requirements are: age first received solid food, age stopped breastfeeding,and presence of month-long cough from any round. No variables were entered for residuals from height (r-4) on height (r-3) and age.

*/> s 0.05 **p s 0.01 ***p s 0.001

RESIDUALS OF: o

: 3WEIGHT HEIGHT WEIGHT HEIGHT WEIGHT :-(r-2) on (r-2) on (r-3) on (r-3) on (r-4) on O

WEIGHT HEIGHT WEIGHT HEIGHT WEIGHT $INDEPENDENT (r-1) and (r-1) and (r-2) and (r-2) and (r-3) and d

VARIABLE AGE AGE AGE AGE AGE {_

intercept jj*HEMOGLOBIN (g/ -0.118** 0.283* 2dl) ( - 0 .202 , -0 .032 ) (0.013,0.549) %SEX (0 = F. 1 = M) 0.602*** 1.026* 0.456s ^

(0.268,0.937) (0.201.1.853) (0.101.0.811) £HOUSEHOLD SIZE 0.290* g

(0.030,0.551) OEXPTL GROUP -0.012s X(0 = C. I = E) (-O.795.-O.O85) [_,adjusted R: 0.064 0.020 0.028 0.033 0.039 'sig. of F statistic 0.005 0.029 0.007 0.010 0.003 QN 186 189 226 218 235 C

2

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between poor and economically well-off children under age five have been largelyattributed to environmental factors (Habicht et al., 1974). Furthermore, studiesof Southeast Asian refugee children provide evidence of better nutritional statusamong American children with Asian descent compared to newly-arrived refugeechildren (Peck et al., 1981) and indicate improvements in weight and height status(Schumacher, Pawson, and Kretchmer, 1987) and birthweight (Li et al., 1990)after arriving in the United States. However, first-generation Southeast Asianrefugee children still exhibit growth below the NCHS reference population (Bald-win and Sutherland, 1988).

In the study by Vu and Han (1984), weights and heights of young childrenwere measured between 1972 and 1975 and again between 1976 and 1980 in severalnorthern provinces. They briefly mentioned that, compared to the early-1970'ssample, children from the late-1970's sample had better weight gain between theages of one and two years. Although variables that may have influenced growthwere not measured, the authors attributed improvement to specific behaviorstargeted at children aged 7-18 months: (1) increased protein content in "an es-sentially starchy diet" before and after weaning and (2) decreased morbidity dueto improved hygiene, vaccinations at creches and use of traditional medicinalplants.

Hemoglobin levels were typically substandard (Table VIII) throughout thesurvey. The World Health Organization (1972) considers 11 g/dl the hgb con-centration below which anemia is likely to be present. It is not clear if low hgblevels observed in this population were the result of poor iron nutriture, malaria,or parasitic infections resulting in blood loss. Malaria is the leading cause of childmortality in Vietnam, although incidence in the northern parts of the countrymay be less due to interrupted transmission during the cold season (UNICEF,1990). Additionally, UNICEF (1990) estimates that approximately 90% of thepopulation is infested with one or more types of intestinal worm, including hook-worm. These data suggest that the observed anemia may be due, at least in part,to malaria and/or intestinal parasites.

Regression Analyses

Greater age was negatively associated with attained nutritional status but posi-tively associated with longitudinal growth. Standardization takes into accountdifferences in growth rates according to age. Many studies have observed a neg-ative association between attained nutritional status and age (Nguyen, Pham andWeitzel, 1990; Cousens, Mertens and Fernando, 1990; Powell and Grantham-McGregor, 1985; Smith et al., 1983; Jumaan et al., 1989; Bhuiya, Wojtyniak andKarim, 1989; Kielmann, Neuvians and Mtango, 1989; Christian et al., 1989). Theobservation that older children have poorer W/A and H/A but better growthincrements suggests that catch-up growth is occurring at some level. Because ofa greater deficit in weight and height, growth rates are higher among older childrenin an attempt to achieve a more normal attained growth status (Ashworth andMillward, 1986). This does not imply, however, that these children will ever reachtheir full growth potential.

Weaning variables displayed weak associations with nutritional outcome, theexception being a positive association between mean hgb and age of first solidfood. This positive association suggests that later introduction of solids may de-crease contact with pathogens thus leading to better hgb status in an area with ahigh prevalence of intestinal worm infestation (UNICEF, 1990). This is supported

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by a marginal but positive association between age at which breastfeeding stoppedand mean hgb (data not shown). Since age at which breastfeeding stopped andage first received solid food were positively correlated, the combination of pro-longed breastfeeding and delayed introduction of solid foods may be a beneficialweaning strategy.

Studies that report associations between weaning variables and various healthoutcomes indicate that breastfeeding is positively associated with W/A (Jumaanet al., 1989; Kielmann, Neuvians and Mtango, 1989) and decreased infant mor-tality (DaVanzo, 1988). The introduction of solid foods shows more variability:no statistical association with W/A (Jumaan et al., 1989), a later introduction wasassociated with better W/A (Smith et al., 1983), and an earlier introduction waspositively associated with weight gain (Zumrawi, 1991).

The analyses here indicate few consistent relationships between nutritionaloutcome and household-level variables which could be targeted for interventionprograms. Age displays consistency in its associations, and, although age is nota variable that can be altered, it is important to know the age groups for whichinterventions should be targeted. The target population identified here is olderchildren with respect to W/A and H/A. Clearly there were unmeasured factorsthat had a negative impact on growth and that masked any beneficial impact ofappropriate weaning practices. Weaning practices do not explain the poor growthobserved during the first year of life (Figures 4-6). One may speculate thatmaternal nutrition was inadequate throughout pregnancy and lactation, resultingin inadequate milk production (Krasovec, 1991; Popkin et al., 1986). Further-more, and perhaps more important, food security in the northern region is tenuousdue to the vagaries of weather (Nuttonson, 1963; Food and Agricultural Orga-nization, 1986), a heavy reliance on rice as a primary foodstuff (Economist In-telligence Unit, 1990), and high population density (Fraser, 1988 and Beresford,1988). In residual analyses, being male was positively associated with growthduring several rounds. A bias toward male infants is a common observation instudies of nutritional status and is consistent with Confucianism, which valuesmen above women (Mackerras, 1988; Vietnamese Women's Union and Centrefor Women Studies, 1989). Although the Vietnamese government officially es-pouses equality between sexes, remnants of the Confucian ethos remain (Viet-namese Women's Union and Centre for Women Studies, 1989). The positiveassociation between hgb and the residual of height (round 3) does not necessarilycontradict the negative result found with weight. Growth in height is a slowerprocess such that the time needed for increases in stature may be adequate forconcomitant increases in hgb.

More consistency in associations between various independent variables andnutritional outcomes was probably not observed for several reasons. First, therewas missing data for numerous cases. Although there is no clear consensus amongstatisticians on the treatment of missing data in a multivariate analysis such asthis, plugging missing data holes with mean values of independent variables hasbeen suggested as one way to exploit the power of the sample size without undulydistorting other relationships in the simultaneous analysis (Cohen and Cohen,1975). Second, there was a lack of precision in height/length (1.0 vs. 0.1 cm)measurements. This consistent lack of precision would result primarily in mis-classification of children as undernourished/not undernourished (in terms ofheight for age) and second, diminishes the ability of the regression models topredict outcomes. This analysis grouped children into Z-score ranges for descrip-tive purposes; misclassification is as likely for the better nourished children as

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well as for the poorly nourished. Although a lack of precision is a concern, thepurpose of this paper is to describe the general situation of nutritionally at-riskchildren and to attempt to obtain a better understanding of the general relation-ships between outcome and independent variables. This paper does not attemptto predict nutritional outcomes or give definitive estimates of undernutrition.Third, there is inherent recall error in obtaining weaning data. This may havebeen minimized by excluding children over three years at the baseline survey.However, mean ages of weaning and introduction of first solid food are consistentwith other reported values for Vietnamese women (UNICEF, 1990; Mandersonand Mathews, 1981; Calhoun, 1985). Fourth, not all children participated in eachsurvey round. This may introduce various types of bias (i.e., loss of cases due todeath or illness) which may distort trends in growth. Finally, a narrow range ofhousehold variables was measured; most of the variation observed in the nutri-tional indicators is not attributable to the factors reported here.

Despite these limitations, the significance of this analysis is that it reports thenutritional status of a grossly under-researched population. It also demonstratesthe need for more comprehensive data collection to better understand the complexweb of interactions leading to nutritional outcomes and the ways in which healthand nutritional needs can be met. This study covered a limited geographical areaof six provinces. There is a need for high-coverage surveillance at the nationallevel to identify those most in need of assistance and to identify factors amenableto intervention. The alarming prevalence of undernutrition observed here and byothers (Vu and Han, 1984; Nguyen, Pham and Weitzel, 1990) calls for immediateattention from the international health community.

ACKNOWLEDGEMENTS

The authors are grateful for the assistance and expertise of Nancy D. Volk who contributed to theimplementation of the program and managed the data files. The authors also appreciate the helpfulcomments of two anonymous reviewers. The primary health care program was supported by fundsfrom the Christopher Reynolds Foundation.

REFERENCES

Ashworth, A. and D.J. Millward (1986). Catch-up growth in children. Nutrition Reviews, 44, 157-163.

Baldwin, L.-M. and S. Sutherland (1988). Growth patterns of first-seneration Southeast Asian infants.Amer. J. Dis. Childhood. 142. 526-531.

Baumgartner. R.N.. A.F. Roche and J.H. Himes (1986). Incremental growth tables: supplementaryto previously published charts. Am. J. Clin. Nutr.. 43. 711-722.

Beresford, M. (1988). Vietnam: Politics. Economics and Society. Pinter Publishers. London.Bhuiya, A., B. Wojtyniak. and R. Karim (1989). Malnutrition and child mortality: are socioeconomic

factors important? J. Biosoc. Sci., 21. 357-364.Briend, A., K. Hasan, K.M.A. Aziz, B.A. Hoque and F.J. Henry (1989). Measuring change in

nutritional status: a comparison of different anthropometric indices and the sample sizes required.Eur. J. Clin. Nutr., 43. 769-778.

Calhoun, M.A. (1985). The Vietnamese woman: health/illness attitudes and behaviors. Health Curefor Women International. 6. 61-72.

Christian, P., R. Abbi, S. Gujral and T. Gopaldas (1989). Socioeconomic determinants of childnutritional status in rural and tribal India. Ecology of Food Nutr., 23. 31-38.

Cohen, J. and P. Cohen (1975). Applied Multiple Regression/Correlation Analysis for the BehavioralSciences. Lawrence Erlbaum Associates. Hillsdale. New Jersey, pp. 265-290.

Cousens, S.N., T.E. Mertens and M.A. Fernando (1990). The anthropometric status of children inKurunegala district in Sri Lanka: its relation to water supply, sanitation and hygiene practice.Tropical Med. Parasit., 41. 105-114.

Dow

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ity o

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at T

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a] a

t 17:

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254 S. SHOFF. J. CSETE, J. LADINSKY AND H. T. NGUYEN

DaVanzo, J. (1988). Infant mortality and socioeconomic development: evidence from Malaysianhousehold data. Demography. 25. 581-595.

Doan, R.M. and L. Bisharat (1990). Female autonomy and child nutritional status: the extended-family residential unit in Amman. Jordan. Soc. Sci. Med., 31. 783-789.

Economist Intelligence Unit (1990). Indochina: Vietnam. Laos. Cambodia. Country Profile 1990-91.The Economist Intelligence Unit Limited. London.

Esrcy, S.A., G. Casella and J.-P. Habicht (1990). The use of residuals for longitudinal data analysis:the example of child growth. Am. J. Epidemiology. 131. 365-372.

Evatt, B.L., S.M. Lewis, F. Lothe and J.R. MacArthur (1983). Anemia. Fundamental DiagnosticHematology, U.S. Department of Health and Human Services. Public Health Service and Centersfor Disease Control. Atlanta.

Eveleth, P.B. and J.M. Tanner (1976). Worldwide Variation in Human Growth. Cambridge UniversityPress, Cambridge, chapter 5.

Far Eastern Economic Review (1991). Asia Yearbook. Hong Kong. pp. 234-240.Fforde, A. and S. de Vylder (1988). Vietnam—An Economy in Transition. Swedish International

Development Authority. Stockholm.Food and Agriculture Organization (1986). The Socialist Republic of Viet Nam: Assessment of the

Food. Agriculture and Livestock Situation. Office for Special Relief Operations. FAO. Rome.Fraser, S.E. (1988). Vietnam's exploding population. In C. Mackerras. R. Cribb and A. Healy. (Eds).

Contemporary Vietnam: Pespeclives from Australia. University of Wollongong Press.Grantham-McGregor, S.M., C.A. Powell, S.P. Walker and J.H. Himes (1991). Nutritional supple-

mentation, psychosocial stimulation, and mental development of stunted children: the Jamaicanstudy. Lancet. 338. 1-5.

Habicht, J.-P., R. Martorell, C. Yarbrough, R.M. Malina and R.E. Klein (1974). Height and weightstandards for preschool children. How relevant are ethnic differences in growth potential? Lancet.April 6, 611-615.

Hamill, P.V., T.A. Drizd, C.L. Johnson, R.B. Reed and E.F. Roche (1977). NCHS Growth Curvesfor Children. Birth-18 Years. United States. National Center for Health Statistics. Hyattsville.Md.

Jelliffe, D.B. (1966). The assessment of the nutritional status of the community. WHO MonographSeries, no. 53: 50-78.

Johnston, F.E. (1981). Physical growth and development and nutritional status: epidemiological con-siderations. Federation Proceedings. 40. 2583-2587.

Jordan. M.D. (1987). Anthropometric Software Package. Centers for Disease Control. Atlanta. Ga.Jumaan, A.O., M.K. Serdula, D.F. Williamson, M.J. Dibley, N.J. Binkin and J.J. Boring (1989).

Feeding practices and growth in Yemeni children. J. Trop. Pediatrics. 35. 82-86.Kielmann, A.A., D. Neuvians and F.D.E. Mtango (1989). Who is the child at risk? Tropical Med.

Parasit., 40. 400-404.Krasovec, K. (1991). The implication of poor maternal nutritional status during pregnancy for future

lactational performance. J. Tropical. Ped., 37. 3-10.Launer, L.J., J.-P. Habicht and S. Kardjati (1990). Breast feeding protects infants in Indonesia against

illness and weight loss due to illness. Am. J. Epidemiology. 131. 322-331.Li, D.-K., N. Hanyu, S.M. Schwartz and J.R. Daling (1990). Secular change in birthweight among

Southeast Asian immigrants to the United States. Amer. J. Public Health. 80. 685-688.Mackerras, C. (1988). Women in contemporary Vietnam. In C. Mackerras. R. Cribb and A. Healy.

(Eds). Contemporary Vietnam: Perspectives from Australia. University of Wollongong Press.Manderson, L. and M. Mathews (1981). Vietnamese attitudes towards maternal and infant health.

Med. J. Aust., 1. 69-72.Nguyen, G., K.N. Pham and V. Weitzel (1990). Some biological parameters of children from I to 5

years of age in two ecological regions of Thai Binh province. Vietnam. In L. Frecdman (Ed). IsOur Future Limited by Our Past?. Australian Society for Human Biology. University of WesternAustralia.

Nuttonson, M. Y. (1963). The Physical Environment and Agriculture of Vietnam. Laos and Cambodia.American Institute of Crop Ecology. Washington. D.C.

Peck, R.E., M. Chuang, G.E. Robbins and M.Z. Nichaman (1981). Nutritional status of SoutheastAsian refugee children. Amer. J. Public Health. 71. 1144-1148.

Popkin, B.M. and M.E. Yamamoto (1985). A comparison of anthropometric classifications for nu-tritional status determination: a case study in the Philippines. J. Tropical Ped., 31. 311-319.

Popkin, B.M., T. Lasky, J. Litvin, D. Spicer and M.E. Yamamoto (1986). The Infant-Feeding Triad.Infant. Mother, and Household. Gordon and Breach. New York. Chapter 5. pp. 83-120.

Powell, C.A. and S. Grantham-MacGrcgor (1985). The ecology of nutritional status and developmentin voung children in Kingston. Jamaica. Am. J. Clin. Nutr., 41. 1322-1331.

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Rao, S. and A. Kanade (1988). Comparison of Gomez and Watcrlow classifications in a follow-upstudy among prc-school children. Eur. J. Clin. Nuir., 42. 863-869.

Schumacher, L.B., G. Pawson and N. Kretchmer (1987). Growth of immigrant children in the New-comer schools of San Francisco. Pediatrics, 80, 861-868.

Smith. M.F., S.K., Paulsen. W. Fougere and S.J. Ritchey (1983). Socioeconomic. education and healthfactors influencing growth of rural Haitian children. Ecology Food Nuir., 13. 99-108.

Tanumidjaja, T.M. (1982). General condition of children in trie Indo-Chinese Peninsula and type ofUNICEF programmes. Southeast Asian J. Trop. Meet., 13. 301-305.

UNICEF (1991). State of the World's Children 1991. Oxford University Press. New York.UNICEF (1990). Viet Nam. the Situation of Children and Women. Hanoi.Vietnamese Women's Union and Centre for Women Studies (1989). Vietnamese Women in the Eighties.

Hanoi.Vu, T.C. and K.C. Han (1984). Growth of the Vietnamese child. Vietnamese Studies. 74. 39-44.

Hanoi.Waterlow, J.C., R. Buzina, W. Ketter, J.M. Lane, M.A. Nichaman and J.M. Tanner (1977). The

presentation and use of height and weight data for comparing the nutritional status of groups ofchildren under the age of 10 years. Bulletin of the World Health Organization. 55. 489-498.

World Health Organization (1972). Nutritional Anemia. WHO Technical Report Series No. 3. WHO.Geneva.

Williams. P.D. and A.R. Williams (1989). Mild malnutrition and child development in the Philippines.Western J. Nursing Res., 11, 310-319.

Zhang, X. and Z. Huang (1988). The Second National Growth and Development Survey of Childrenin China. 1985: children 0 to 7 years. Ann. Human Biology, 15, 289-305.

Zumrawi, F.Y. (1991). Effects of the relative importance of different factors and their degree ofinteractions on child growth, J. Tropical Ped., 37. 131-135.

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nutritional status of preschool children in northern vietnam

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