title: Household food access and child malnutrition: results from the eight-country MAL-ED study.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Fogarty International Center, National Institutes of Health, Bethesda, USA. wcheckl1@jhmi.edu.
authors.forename: Stephanie
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authors.lastname: Psaki
authors.forename: Zulfiqar A
authors.initials: ZA
authors.lastname: Bhutta
authors.forename: Tahmeed
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authors.lastname: Ahmed
authors.forename: Shamsir
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authors.lastname: Ahmed
authors.forename: Pascal
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authors.lastname: Bessong
authors.forename: Munirul
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authors.lastname: Islam
authors.forename: Sushil
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authors.lastname: John
authors.forename: Margaret
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authors.lastname: Kosek
authors.forename: Aldo
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authors.lastname: Lima
authors.forename: Cebisa
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authors.lastname: Nesamvuni
authors.forename: Prakash
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authors.lastname: Shrestha
authors.forename: Erling
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authors.lastname: Svensen
authors.forename: Monica
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authors.lastname: McGrath
authors.forename: Stephanie
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authors.lastname: Richard
authors.forename: Jessica
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authors.lastname: Seidman
authors.forename: Laura
authors.initials: L
authors.lastname: Caulfield
authors.forename: Mark
authors.initials: M
authors.lastname: Miller
authors.forename: William
authors.initials: W
authors.lastname: Checkley