title: Assessing comorbidity and correlates of wasting and stunting among children in Somalia using cross-sectional household surveys: 2007 to 2010.
abstract: OBJECTIVE
  Wasting and stunting may occur together at the individual child level; however, their shared geographic distribution and correlates remain unexplored. Understanding shared and separate correlates may inform interventions. We aimed to assess the spatial codistribution of wasting, stunting and underweight and investigate their shared correlates among children aged 6-59 months in Somalia.
  
  
  METHODS
  Cross-sectional nutritional assessments surveys were conducted using structured interviews among communities in Somalia biannually from 2007 to 2010. A two-stage cluster sampling methodology was used to select children aged 6-59 months from households across three livelihood zones (pastoral, agropastoral and riverine). Using these data and environmental covariates, we implemented a multivariate spatial technique to estimate the codistribution and divergence of the risks and correlates of wasting and stunting at the 1 × 1 km spatial resolution.
  
  
  METHODS
  73,778 children aged 6-59 months from 1066 survey clusters in Somalia.
  
  
  RESULTS
  Observed pairwise child level empirical correlations were 0.30, 0.70 and 0.73 between weight-for-height and height-for-age; height-for-age and weight-for-age, and weight-for-height and weight-for-age, respectively. Access to foods with high protein content and vegetation cover, a proxy of rainfall or drought, were associated with lower risk of wasting and stunting. Age, gender, illness, access to carbohydrates and temperature were correlates of all three indicators. The spatial codistribution was highest between stunting and underweight with relative risk values ranging between 0.15 and 6.20, followed by wasting and underweight (range: 0.18-5.18) and lowest between wasting and stunting (range: 0.26-4.32).
  
  
  CONCLUSIONS
  The determinants of wasting and stunting are largely shared, but their correlation is relatively variable in space. Significant hotspots of different forms of malnutrition occurred in the South Central regions of the country. Although nutrition response in Somalia has traditionally focused on wasting rather than stunting, integrated programming and interventions can effectively target both conditions to alleviate common risk factors.
authors.affiliation: Spatial Health Metris Group, INFORM Project, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya.
authors.forename: Damaris K
authors.initials: DK
authors.lastname: Kinyoki
authors.affiliation: Warwick Medical School, Health Sciences Research Institute, University of Warwick, Warwick Evidence, Coventry, UK Department of Mathematics and Information sciences, Faculty of Engineering and Environment, Northumbria University, Newcastle upon Tyne, UK Department of Population Health, Luxembourg Institute of Health (LIH), Strassen, Luxembourg.
authors.forename: Ngianga-Bakwin
authors.initials: NB
authors.lastname: Kandala
authors.affiliation: Biostatistics Research Unit, South African Medical Research Council, Pretoria, South Africa Division of Epidemiology and Biostatistics, School of Public Health, University of Witwatersrand, Johannesburg, South Africa.
authors.forename: Samuel O
authors.initials: SO
authors.lastname: Manda
authors.affiliation: Department of Mathematical Sciences, Norwegian University of Science and Technology, Trondheim, Norway Department of Statistics, Federal University of Paraná, Curitiba, Brazil.
authors.forename: Elias T
authors.initials: ET
authors.lastname: Krainski
authors.affiliation: Department of Mathematical Sciences, Norwegian University of Science and Technology, Trondheim, Norway.
authors.forename: Geir-Arne
authors.initials: GA
authors.lastname: Fuglstad
authors.affiliation: Nutrition Section, United Nations Children's Fund (UNICEF), Kenya Country Office, UN Complex Gigiri, Nairobi, Kenya.
authors.forename: Grainne M
authors.initials: GM
authors.lastname: Moloney
authors.affiliation: Kenya Medical Research Institute/Wellcome Trust Research Programme, Centre for Geographic Medicine Research (coast), Kilifi, Kenya Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
authors.forename: James A
authors.initials: JA
authors.lastname: Berkley
authors.affiliation: Spatial Health Metris Group, INFORM Project, Kenya Medical Research Institute/Wellcome Trust Research Programme, Nairobi, Kenya Nuffield Department of Clinical Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
authors.forename: Abdisalan M
authors.initials: AM
authors.lastname: Noor
mesh_terms: D002675:Child, Preschool; D015897:Comorbidity; D003430:Cross-Sectional Studies; D004032:Diet; D005191:Family Characteristics; D005260:Female; D006130:Growth Disorders / Q000453:epidemiology* / Q000209:etiology; D006801:Humans; D007223:Infant; D008297:Male; D015999:Multivariate Analysis; D009749:Nutrition Surveys; D009752:Nutritional Status; D012998:Somalia / Q000453:epidemiology; D013851:Thinness / Q000453:epidemiology* / Q000209:etiology; D019282:Wasting Syndrome / Q000453:epidemiology* / Q000209:etiology
keywords: Geo-statistics; malnutrition; shared-component; stunting; underweight; wasting