Association of early nutritional status with child development in the Asia Pacific Region

Frederick K. HO, Nirmala RAO, Keith T. S. TUNG, Rosa Sze Man WONG, Wilfred H. S. WONG, Joanna Y. L. TUNG, Gilbert T. CHUA, Winnie W. Y. TSO, John BACON-SHONE, Ian C. K. WONG, Aisha YOUSAFZAI, Charlotte WRIGHT, Patrick IP

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5 Citations (Scopus)


Importance: Stunting was used as a proxy for underdevelopment in early childhood in previous studies, but the associations between child development and other growth and body composition parameters were rarely studied. 

Objective: To estimate the association between malnutrition and early child development (ECD) at an individual level. 

Design, Setting, and Participants: This population-based, cross-sectional study used data from the East Asia Pacific Early Child Development Scales, a population-representative survey of children aged 3 to 5 years old, conducted in 2012 to 2014 in communities in Cambodia, China, Mongolia, Papua New Guinea, and Vanuatu. Data analysis was performed from November 2019 to April 2021. 

Exposures: Stunting (height-for-age [HFA] z score less than -2), wasting (weight-for-height z score less than -2), overweight (weight-for-height z score greater than 2), body mass index (BMI)-for-age z score, and body fat proportion based on existing growth standard and formula. 

Main Outcomes and Measures: ECD directly assessed using the validated East Asia-Pacific ECD Scales. 

Results: A total of 7108 children (3547 girls; mean [SD], age 4.48 [0.84] years) were included in this study. The prevalence of stunting was 27.1% (range across countries, 1.2%-55.0%), that of wasting was 13.7% (range, 5.4%-35.9%), and that of overweight was 15.9% (range, 2.2%-53.7%). Adjusted for country variations, age, sex, urbanicity, family socioeconomic status, and body fat proportion, ECD was linearly associated with HFA (β, 1.57; 95% CI, 1.35-1.80) and BMI-for-age (β, 0.64; 95% CI, 0.45-0.82). After adjustment for BMI and height, better ECD was associated with low body fat proportion (β, 0.93; 95% CI, 0.45-1.42). The association of HFA was more pronounced in Southeast Asia and the Pacific region than in East Asia, and the association of fat proportion was specific to children living in urban environments. 

Conclusions and Relevance: HFA, BMI-for-age, and body fat proportion were independently associated with ECD, and these findings suggest that future studies should consider using these parameters to estimate the prevalence of child underdevelopment; nutritional trials should examine to what extent the associations are causal. Copyright© 2021 Ho FK et al.

Original languageEnglish
Article numbere2139543
JournalJAMA Network Open
Issue number12
Publication statusPublished - Dec 2021


Ho, F. K., Rao, N., Tung, K. T. S., Wong, R. S., Wong, W. H. S., Tung, J. Y. L., Chua, G. T., Tso, W. W. Y., Bacon-Shone, J., Wong, I. C. K., Yousafzai, A., Wright, C., & Ip, P. (2021). Association of early nutritional status with child development in the Asia Pacific Region. JAMA Network Open, 4(12), Article e2139543.


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