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Household food access and child malnutrition: results from the eight-country MAL-ED study

Stephanie Psaki12, Zulfiqar A Bhutta3, Tahmeed Ahmed4, Shamsir Ahmed4, Pascal Bessong5, Munirul Islam4, Sushil John6, Margaret Kosek2, Aldo Lima9, Cebisa Nesamvuni5, Prakash Shrestha7, Erling Svensen8, Monica McGrath12, Stephanie Richard12, Jessica Seidman12, Laura Caulfield2, Mark Miller1, William Checkley1102* and for MALED Network Investigators

Author Affiliations

1 Fogarty International Center, National Institutes of Health, Bethesda, USA

2 Program in Global Disease Epidemiology and Control and Division of Human Nutrition, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA

3 Division of Women and Child Health, Aga Khan University, Karachi, Pakistan

4 International Centers for Diarrheal Disease Research, Matlab, Bangladesh

5 University of Venda, Thohoyandou, South Africa

6 Christian Medical College, Vellore, India

7 Institute of Medicine, Kathmandu, Nepal

8 University of Bergen, Bergen, Norway

9 Federal University of Ceara, Fortaleza, Brazil

10 Division of Pulmonary and Critical Care, School of Medicine, Johns Hopkins University, Suite 9121 1800 Orleans Street, 21212, Baltimore, MD, USA

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Population Health Metrics 2012, 10:24  doi:10.1186/1478-7954-10-24

Published: 13 December 2012



Stunting results from decreased food intake, poor diet quality, and a high burden of early childhood infections, and contributes to significant morbidity and mortality worldwide. Although food insecurity is an important determinant of child nutrition, including stunting, development of universal measures has been challenging due to cumbersome nutritional questionnaires and concerns about lack of comparability across populations. We investigate the relationship between household food access, one component of food security, and indicators of nutritional status in early childhood across eight country sites.


We administered a socioeconomic survey to 800 households in research sites in eight countries, including a recently validated nine-item food access insecurity questionnaire, and obtained anthropometric measurements from children aged 24 to 60 months. We used multivariable regression models to assess the relationship between household food access insecurity and anthropometry in children, and we assessed the invariance of that relationship across country sites.


Average age of study children was 41 months. Mean food access insecurity score (range: 0–27) was 5.8, and varied from 2.4 in Nepal to 8.3 in Pakistan. Across sites, the prevalence of stunting (42%) was much higher than the prevalence of wasting (6%). In pooled regression analyses, a 10-point increase in food access insecurity score was associated with a 0.20 SD decrease in height-for-age Z score (95% CI 0.05 to 0.34 SD; p = 0.008). A likelihood ratio test for heterogeneity revealed that this relationship was consistent across countries (p = 0.17).


Our study provides evidence of the validity of using a simple household food access insecurity score to investigate the etiology of childhood growth faltering across diverse geographic settings. Such a measure could be used to direct interventions by identifying children at risk of illness and death related to malnutrition.