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 Table of Contents  
Year : 2021  |  Volume : 1  |  Issue : 1  |  Page : 29-36

Dietary intakes, eating habits and socioeconomic determinants of childhood malnutrition among children under 5 years of age in rural Lingshui county, Hainan, China: A case-control study

1 Laboratory of Tropical Environment and Health, School of Public Health, Hainan Medical University, Haikou, Hainan, P. R. China
2 Division of Public Health, Department of Family & Preventive Medicine, University of Utah School of Medicine; Huntsman Cancer Institute, Salt Lake City, Utah, USA
3 Division of Public Health, Department of Family & Preventive Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA

Date of Submission27-Mar-2020
Date of Decision14-Sep-2021
Date of Acceptance22-Sep-2021
Date of Web Publication03-Nov-2021

Correspondence Address:
Fan Zhang
Laboratory of Tropical Environment and Health, School of Public Health, Hainan Medical University, Haikou, Hainan
P. R. China
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2773-0344.329467

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Objective: To investigate the associations between dietary intakes, eating habits, socioeconomic determinants and malnutrition in children under 5 years old in south China.
Method: A case-control study with 182 malnourished (case) and 254 normal (control) children was conducted in four towns using anthropometric measurements and questionnaires.
Results: The dietary intakes of calory, protein, vitamin and minerals of malnourished children were lower than their normal counterparts. Overall, 37.9% children ‘monthly or never’ ate egg and egg products, 61.5% ‘monthly or never’ ate beans and soy products, but 76.7% had candies or cakes ‘daily or weekly’. Four identified determinants of malnutrition were: 1) low education level of mother (OR 1.65; 95% CI 1.02-2.67); 2) more children in one family (OR 1.86; 95% CI 1.14-3.03); 3) absence of independent eating habit (OR 1.75; 95% CI 1.13-2.72); and 4) long dining time (≥20 min) (OR 1.91; 95% CI 1.12-3.24).
Conclusions: Inadequate dietary intake, lower socioeconomic status and inappropriate eating habits were the major determinants of childhood malnutrition in south China. Nutritional intervention focusing on education and behavior change are warranted to help reduce the rate of malnourishment among the children of rural families in the future.

Keywords: Public health; Children under five years old; Malnutrition; Case-control study

How to cite this article:
Zhang F, Lee YCA, Yi C, Alder SC, Lin G, He L. Dietary intakes, eating habits and socioeconomic determinants of childhood malnutrition among children under 5 years of age in rural Lingshui county, Hainan, China: A case-control study. One Health Bull 2021;1:29-36

How to cite this URL:
Zhang F, Lee YCA, Yi C, Alder SC, Lin G, He L. Dietary intakes, eating habits and socioeconomic determinants of childhood malnutrition among children under 5 years of age in rural Lingshui county, Hainan, China: A case-control study. One Health Bull [serial online] 2021 [cited 2022 Dec 2];1:29-36. Available from: http://www.johb.info/text.asp?2021/1/1/29/329467

  1. Introduction Top

Worldwide, malnutrition is a major health challenge for children under 5 years old. It is estimated that stunting, severe wasting, and intrauterine growth restriction together are responsible for 2.2 million deaths and 21% of disability-adjusted life-years for children under five years[1]. Lower urban malnutrition was found due to a series of more favorable socioeconomic conditions which in turn lead to better caring practices for children and their mothers in a study of 36 countries from South Asia, Sub-Saharan Africa, Latin America and the Caribbean[2]. Child malnutrition is highly prevalent in low- and middle-income countries; however, the nutritional status varies around the world. In sub-Saharan African countries, the differentials in child malnutrition by place of residence have substantially narrowed over time, primarily due to an increase in urban malnutrition[3]. In south Asian countries, there are substantial rural-urban differences with the incidence of poverty being lower in urban areas[4]. China has been experiencing remarkable economic growth since 1980’. In the past 30 years, the structure of traditional Chinese diet of low fat high carbohydrate shifted to higher fat and protein with improved income, particularly in the low- and middle-income groups[5]. In China, income growth is associated with less severe inequality, while rural-urban gap, provincial differentials, and unequal distribution of the educational levels of head of household are associated with higher levels of inequality in childhood malnutrition[6]. In 2002, the national health survey reported prevalence rates of respectively 14.3% and 7.8% Children under five years old in stunting and underweight growth, with higher rates in less developed areas[7]. Hainan, one of the poorest provinces in China, is located on the southernmost boarder and is closest to other Southeast Asian countries, such as Vietnam. At the end of 2011, the per capita net income of rural households in Hainan was 6 446 yuan per year (1 023 USD) comparing with the national average of 6 977 yuan (1 107 USD)[8].

In a community-based dietary survey, 24-hour dietary recall and food frequency questionnaire (FFQ) are frequently used. FFQ reflects the dietary information of individuals’ food consumption or nutrient intake over a one year or longer period, and can provide the dietary patterns of certain population groups as well as providing information to assess the relationship between diet, nutrition and chronic disease. Compared with other dietary survey methods, FFQ is often less costly and more feasible. FFQ is also considered to be both reliable and valid when compared against 24-hour recall, either in western or eastern diet[9],[10]. Consequently, FFQ is an appropriate instrument to measure the usual food consumption and nutrient intake for both adults and children in many countries[9-11].

The aims of our study were: 1) to compare the dietary intakes of malnourished children with their nourished counterparts; 2) to investigate the existing eating habits among rural children; 3) to identify the link between socioeconomic determinants and poor eating habits; and 4) to provide guidance for developing a nutritional intervention strategy in the study area.

  2. Subjects and methods Top

2.1. Study area and settings

Lingshui is located on the southeast of Hainan Island and is 80 km away from the southernmost Chinese city of Sanya. The land area of Lingshui is 1 128 km2. The total population is 320 400 with 54.3% coming from the Li minority ethnic group. The population of children under five years old was 24 426 in 2010. Lingshui County was selected as the study area for its low-income level and relatively high (6.06%) moderate and severe rate of malnutrition rate for children under five years old in 2010. For this study, four towns were randomly selected in the east, west, south and north regions of Lingshui, with two of them inland and two coastal.

2.2. Study design and recruitment of participants

A case-control study was designed to compare the dietary intakes, food habits and potential influence factors in 436 malnourished and normal children from rural Lingshui. The fieldwork of Lingshui study was conducted in July 2011. Among the participants recruited using a multi-stage sampling method, with the initial figure of 200 malnourished children and 200 normal children. Demographic and geographic information of Lingshui were collected from local government at stage 1. At stage 2, all towns in Lingshui were stratified as inland and coastal strata and four study towns were randomly selected from the two strata. At stage 3, non-probability sampling method was used for the first 50 malnourished children of each town by checking their lastest growth records which were collected in June 2011 by local health workers. Among the 200 selected ‘malnourished’ children, 13 were found as ‘normal’ during the measurements in our study in July 2011 and we reclassified them. Another five children were out of town. Convenience sampling, consisting of both volunteer and snowball approaches, was applied to recruit, an addition of 41 normal children voluntarily participated in our study. A total of 182 malnourished and 254 normal children aged from 0-60 months were finally included in our study. Informed consent was obtained from all guardians of participants before the survey was administered.

2.3. Ethics apporval

This study was reviewed and approved by the Institutional Review Boards for use of human subjects in research at Hainan Medical University (IRB: X201105002). The procedures of our study were in accordance with the Declaration of Helsinki, as revised in 2013.

2.4. Data collection and analysis

Local health workers accomplished the routine growth check on all children under 5 years old in June 2011, and all data were input to the electronic database-the Provincial Children’s Health Reporting System. In our study, the growth check data in selected towns were collected from the Provincial Children’s Health Reporting System with the permission of the local government and township hospitals.

A total of 21 voluntary 3rd year students of preventive medicine from HMU and 4 first year students of public health from the University of Utah School of Medicine were recruited and trained as the field workers. They were randomly and equally assigned to 4 different study towns. The trained field workers performed the procedures of body measurement, questionnaire interview and data entry.

In our study, body height, body weight, head circumference and upper left arm circumference values of 436 participants were measured. Height, weight and age values were translated into Z score values to assess the nutritional status against population standards. The diagnosis of malnutrition was based on the 2006 World Health Organization Child Growth Standards[12]. Underweight was defined as the weight-for-age Z score ≤-2, stunting was defined as the height-for-age Z score ≤-2, and wasting was defined as the weight-for-height Z score ≤-2. Participants who met the criteria of any type of these three were diagnosed as malnourished[13].

Face-to-face interview questionnaires were designed with the following four parts: 1) general information 2) household characteristics; 3) dietary survey by FFQ; and 4) eating habits. Because children under 12 months were potentially fed by immeasurable breast milk and/or complementary foods, only children aged from 12 to 60 months (n=348) were surveyed for comparison of daily calory and nutrient intake by the FFQ developed from the semi-quantitative Chinese FFQ 2010[9]. In the FFQ, foods were surveyed in 9 category lines: 1) cereals, noodles and grains; 2) vegetables and fruits; 3) beans and soy products; 4) fish, shrimp and other seafood; 5) meats; 6) egg and egg products; 7) milk and dairy products; 8) candies, cakes and other desserts; and 9) beverages including fruit juice and sweetened beverage. The frequencies of consuming foods from these categories were measured as ‘how many times per day/ per week/ per month per year’. The average amount of food intake was recorded in a traditional Chinese unit-‘Liang’ (1 Liang=50 grams).

When calculating the daily calory and nutrients intake, common food (white rice, cucumber, tofu, golden thread fish, pork meat, chicken egg, cow’s milk, three-color candy, and flavored milk beverage) were respectively chosen from each category as the reference food for calculation[9]. Daily food intake was calculated by the frequencies and amounts in grams. Microsoft Excel 2003 was used to convert daily food intake into daily intakes of calory, protein, fat, carbohydrates, dietary fiber, vitamins and minerals. The food-nutrient conversion coefficients were calculated based on the data from the Chinese Food Composition Tables[14]. These daily intakes were compared with the corresponding national recommended values (Reference Nutrient Intake, RNI or Adequate intake, AI)[15]. Intakes lower than 80% of reference values were considered inadequate, and lower than 60% were considered deficient. Intakes of malnourished children were compared with normal counterparts in the same age group.

2.5. Statistical methods

Data analyses were performed using Statistical Package for Social Sciences for Windows version 16.0 (SPSS Inc., Chicago, IL, USA). Descriptive statistics (frequencies, means and standard deviations), Student’ s t-test, Wilcoxon rank-sum test and Chi-square test were used for comparison. One-way analysis of variance models, multivariate unconditional logistic regression analysis and the odd ratios (OR) with 95% confidence intervals (CI) were used to assess the potential risk factors of childhood malnutrition. Confounding factors, including gender, family incomes, and ethnic group were controlled for in the regression model. Statistical significance was based on two-sided α=0.05.

  3. Results Top

A total of 254 normal and 182 malnourished rural children were included in our study. The major types of malnutrition were stunting (130/182, 71.4%) and underweight (95/182, 52.2%). A total of 348 valid FFQ were obtained from parents of children aged 12-60 months including 201 normal and 147 malnourished children. All parents answered the interview questions given by our trained field workers, and the response rate was 100.0%.

3.1. Demographic factors

Han or Li were the major ethic groups of all surveyed children (97.7%, 426/436), with only 2.3% (10/436) from other ethnic groups. In the normal group, 66.5% (169/254) were Han and 31.1% (79/254) were Li; in the malnourished group, 68.1% (124/182) were Han and 29.7% (54/182) were Li. There was no ethnical or gender difference between normal and malnourished groups (χ2 values respectively were 0.124 and 1.832, P values were 0.940 and 0.176). Parents of 186 normal and 134 malnourished children answered the question of family incomes. The annual family incomes were categorized as the following four groups: ‘<10 000 yuan’, ‘10 000-14 999 yuan’, ‘15 000-19 999 yuan’ and ‘>20 000 yuan’ per year. The differences in family income were not found by Wilcoxon rank sum test (Z=-1.020, P=0.308). Consequently, measures of ethnic group, gender and family incomes were not associated with childhood malnutrition condition in rural Lingshui.

3.2. Daily dietary intakes

3.2.1. Comparison of Caloric Intakes

Total caloric intakes of normal boys and girls aged from 12-60 months were detected to be higher than their malnourished counterparts (<0.05, see [Table 1]). The caloric intake of malnourished children was lower than 80% of RNI. The tendency of decreased caloric intake, which was indicated by decreasing RNI, with increasing age, was found in both boys and girls.
Table 1: Comparison of calory intakes in boys and girls with different ages.

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3.2.2. Comparison of macronutrient intakes

The results showed that protein, fat and carbohydrate contributed 18.6%, 13.8% and 67.6% respectively in the normal group and 17.4%, 11.9% and 70.7% in the malnourished group. These results showed the diets were inadequate for either the normal or malnourished children. Fats contributed less than the recommendation whereas carbohydrates and protein contributed more.

The daily protein intakes were above RNIs in all age groups for normal children and were below 80% of RNIs after the age of 36 months for malnourished children [Table 2]. The differences in daily protein intake were statistically significant in all age groups (P<0.05).
Table 2: Comparison of daily protein intakes between normal and malnourished children with different ages (g/d).

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3.2.3. Comparison of vitamin and mineral intakes

[Table 3] shows that the vitamin and mineral intakes of the malnourished children were lower than their normal counterparts (P<0.05) except for vitamin C intake in age 48-60 month group. In age 12-47 months groups, the daily vitamin E and calcium intakes were adequate while the iron and zinc intakes were inadequate and the vitamin A, vitamin C and folate intakes were deficient in normal children. The calcium intake was inadequate and all other micronutrients were deficient in malnourished children. In children of aged 48-60 months, only the daily iron intake was adequate, and all other micronutrients were deficient in both groups.
Table 3: Comparison of daily vitamin and mineral intakes between normal and malnourished children.

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3.2.4. Comparison of dietary structure

[Table 4] shows that grains were the major staple food in rural Lingshui, with the highest intake frequencies among all types of food intake for both the normal and malnourished children (>99%). On average, 37.9% (132/348) of children ‘monthly or never’ ate egg or egg products, 61.5% (214/348) ‘monthly or never’ ate beans or soy products, and 76.7% (267/348) had candies or cakes ‘daily or weekly’. No statistically significant differences in these intakes were observed between the normal and malnourished children (P>0.05). Normal children more frequently ate vegetables and fruits, meats, milk or dairy products and beverage than malnourished children (P<0.05). Combining ‘beans and soy products’, ‘fish, shrimp and other seafood’, ‘meats’, ‘egg and egg products’, and ‘milk and dairy products’ as ‘foods rich of protein’, resulted in intake differences between normal and malnourished children, with normal children more frequently choosing foods rich of protein (χ2=4.997, P=0.025). Results showed ‘less intake of foods rich of protein’ (OR 1.25; 95% CI 1.03-1.52) and ‘less intake of vegetables and fruits’ (OR 4.24; 95% CI 2.04-8.82) were risk factors and ‘more intake of beverage’ (OR 0.54; 95% CI 0.32-0.93) was a protective factor for childhood malnutrition. For all children aged 12-24 months, 49.2% (59/120) indicated having dairy products ‘daily or weekly’ while 56.7% (61/120) ‘monthly or never’ had milk or dairy products. For all children aged 25-60 months, only 34.2% (78/228) indicated having dairy products ‘daily or weekly’ and 65.8% (150/228) ‘monthly or never’ had milk or dairy products. A significant pattern of decreased frequency of milk or dairy products intake with increasing age was found (χ2=6.754, P=0.009).
Table 4: Food intake frequencies of all types of food.

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3.3. One-way analysis of variance for potential risk/protective factors of childhood malnutrition education level of mother

Results showed that the major guardians of surveyed children were mothers (404/436, 92.7%) for both normal and malnourished groups (92.1% vs 93.4%, χ2=0.256, P=0.613). Consequently, mothers were considered to represent guardians of surveyed children. The average years of education of mothers were (8.49±2.64) in the normal and (7.93±2.64) in the malnourished groups (t=2.105, P=0.036). Children were more likely to be malnourished when their mothers with education level lower than junior high school (equal to 9-year education) (χ2=3.955, P=0.047). Having a mother with a low education level was one of the risk factors for childhood malnutrition (OR 1.53; 95% CI 1.01-2.33).

3.3.1. Number of children and order of malnourished child in one family

In the malnourished group, 26.4% (48/182) of the families had only one child, 53.3% (97/182) had two and 20.3% (37/182) had three or more children, while in the normal group, 37.8% (96/254) families had one, 53.1% (135/254) had two and 9.1% (23/254) had three or more children (χ2=13.982, P=0.001). Compared to the one-child family, ‘family with three or more children’ was a risk factor of childhood malnutrition (OR 3.22; 95%CI 1.72-6.01) but ‘family with two children’ was not (OR 1.44; 95% CI 0.93-2.22). Additionally, a difference was also found based on the birth order of children (χ2=10.222, P=0.006). In the malnourished group, 46.2% (84/182) were the eldest, 40.1% (73/182) were the second and 13.7% (25/182) were the third or younger than third in the family. In the normal group, the proportions were 53.5% (136/254), 41.3% (105/254) and 5.2% (13/254) respectively. Compared to ‘the eldest child’, children who were the ‘third or younger’ were at greater risk of malnutrition (OR 3.11; 95% CI 1.51-6.42), but children who were the ‘second’ born were not (OR 1.13; 95% CI 0.75-1.69).

3.3.2. Consumption of snacks

The median monthly amounts of money spent on snacks were 100 (5, 210) yuan in the normal group and 100 (30, 210) yuan in the malnourished group, yet this difference was not statistically significant (Z=0.813, P=0.522).

3.3.3. Independent eating habit

Independent eating habit differed between groups. For the malnourished group, 58.7% (84/143) ‘always or sometimes’ ate independently, versus 73.3% (143/195) of the normal children. Furthermore, 41.3% (59/143) of malnourished and 26.7% (52/195) normal children ‘seldom or never’ ate independently. This difference was statistically significant (χ2=7.965, P=0.005), with the habit of seldom or never independent eating serving as a risk factor of childhood malnutrition (OR 1.80; 95% CI 1.22-3.06).

3.3.4. Eating behaviors during meal

The median dining time for a meal was 20 (15, 30) min in the normal and 30 (20, 30) min in the malnourished. Malnourished group spent more dining time, yet this difference was not statistically significant (Z=1.156, P=0.138). Difference was found between normal and malnourished children when they were divided into the ≥20 and the <20 min groups (χ2=7.676, P=0.006), with more malnourished children (84.1%, 153/182) in the ≥20 min group than their normal counterparts (72.8%, 185/254). Children who spent 20 min or more for a meal were at greater risk for malnutrition (OR 1.97; 95% CI 1.21-3.19). For normal children, 56.3% (143/254) versus 62.6% (114/182) of malnourished children did not concentrate when eating meals, though the difference was not statistically significant (χ2=1.760, P=0.185). Children from both groups were reported by their mothers/ guardians to often play or watch television during dining time.

3.3.5. Habits of food avoidance /preference

Totally 39% (98/254) normal children had habits of food avoidance or preference versus 45.1% (82/182) of malnourished children, though the difference was not statistically significant (χ2=1.832, P=0.176). Vegetables (23.5% in normal and 45.1% in malnourished children) and meats (16.3% in normal and 24.4% in malnourished children) were the top two foods being avoided, and difference was detected between groups (χ2=16.179, P<0.001).

3.4. Multivariate unconditional logistic regression analysis for socioeconomic determinants of childhood malnutrition

A one-way analysis of variance was used to identify variables that were detected to be different between the two groups, and then a multivariate unconditional logistic regression analysis method was used to identify the predictors of childhood malnutrition (α=0.05, β=0.10). Six variables were included as the independent factors which were ‘education level of mother’ (0=junior high school or above, 1=below junior high school), ‘number of children in one family’ (1=one child, 2=two, 3=three or more), ‘birth order of the surveyed child’ (1=the eldest, 2=the second, 3=the third or younger than third), ‘independent eating habit’ (0=yes, 1=no), ‘dining time for a meal’ (0=<20 min, 1=≥20 min) and ‘frequent snack consumption’ (0=no, 1=yes). ‘Education level of mother below junior high school’, ‘more children in one family’, ‘absence of independent eating habit’ and ‘dining time for a meal ≥20 min’ achieved statistical significance as predictors of malnutrition in this multivariate analysis [Table 5].
Table 5: Multivariate unconditional logistic regression analysis for children nutrition.

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  4. Discussion Top

4.1. Existing dietary problems and risky eating habits among children in rural Lingshui

According to the Chinese dietary recommendations for children under five years old, it is suggested that protein should provide 10%-15% of total daily caloric intake, fats should provide 30%-35% and carbohydrates should provide 45%[15]. The intakes of calorie, protein, vitamins and minerals amongst the malnourished children were apparently lower than their normal counterparts. The tendency of decreased caloric intake with increasing age should be noted, especially after the age of 36 months. Moreover, the macronutrients contributed inappropriately in children’s caloric intake, with fats contributing less than the recommended amounts and carbohydrates playing a more substantial role in children’s diet. Interestingly, our study shows similar results to those of a Malawian study which indicated that household fish farming may not contribute to a lower prevalence of malnutrition by increasing protein intake through the elevated consumption of fish[16]. Lingshui is located in a coastal area of Hainan Island in south China, and most of the surveyed children are from fish farming families. Study showed that 85% percent of the malnourished children frequently eat fish, shrimp and other seafood, which was found to be higher than the normal children (73.1%) in the same area. This may be explained by the deficient total amount of seafood and other protein sources intakes despite of the frequency; another possible reason is the increasing household purchasing power for obtaining other types of foods[17], such as snacks and sugary drinks, which might be an indirect influence factor. Frequent snack and beverage consumption is another existing problem in rural Lingshui, with the most common type of beverage being flavored milk beverages. Our study showed that more than 75% of surveyed children frequently had snacks and beverages on a daily or weekly basis. Beverage with high calory content occurs at a higher consumption rate in normal children than the malnourished children (84.6% vs 74.8%, P<0.05, [Table 4]). The possible explanation was more frequent high-calorie beverage consumption resulted in higher energy intake and greater body weight in children. Our study also showed that ‘less intake of foods rich of protein’ (OR 1.25; 95% CI 1.03-1.52) and ‘less intake of vegetables and fruits’ (OR 4.24; 95% CI 2.04-8.82) were risk dietary factors of childhood malnutrition in rural Lingshui. Besides, a research has shown that it takes 10-20 min for a child to have one meal, with the recommendation that this should take no more than 30 min[18], while in our study, the median dining time for a meal was 20 (15, 30) min in the normal and 30 (20, 30) min in the malnourished.

To sum up, in our study, risk factors including high prevalence of food avoidance or preference (avoid vegetables and meats), long dining time (≥20 min), loss of concentration during dining and seldom independent eating were also reported, as well as the habit of frequent snack consumption.

4.2. Socioeconomic determinants of childhood malnutrition in rural Lingshui

Interestingly, our study does not support the hypothesis that children from the Li ethnic group, who are female or who are from poor families are more likely to be malnourished. However, the multivariate unconditional logistic regression analysis results showed that low education level of mother and more children in one family were socioeconomic determinants of childhood malnutrition. An explanation is that the structure of the Chinese diet has been changing with the rapid improvement of incomes since 1990s, particularly in the low- and middle-income groups[5], resulting in a narrowing of the family income gap. The income growth appears to have ameliorated the inequality in childhood malnutrition, while improved household head’s education has disfavored children in low-income households, which is largely due to the inequity of household head’s education status[6],[19]. Compared to family incomes, the education level of mother is a more crucial determinant of childhood malnutrition. In rural Lingshui, families annually spend 1 440-1 680 yuan (120-140 yuan per month, 12 months per year) on snacks which is about one quarter of the per capita net income of rural households in Hainan (6 446 yuan in 2011). The indication is that one of the major determinants of childhood malnutrition in rural Lingshui is not the shortage of financial resources, but the shortage of nutritional education and knowledge of healthy diet to the mothers. Furthermore, parents seem to be able to provide better care to their infants or babies if they have fewer children. Studies showed psychosocial stimulation is critical for the early development of children[20], with a lack of attention and sufficient childcare from the parents as a possible determinant of childhood malnutrition.

4.3. Implications of our findings and further intervention

Despite of the rapid socioeconomic development, double burden of malnutrition is one of the prominent public health challenges in China[21], which means the coexistence of under-nutrition in rural and over-nutrition in urban. Our study results showed that the stunting (71.4%) was the major type of childhood under-nutrition in Lingshui which indicated chronic under-nutrition remains to be child health issues in the study area. In 2010, the top leading causes of deaths in children under five years old were infectious diseases in neonates, and pneumonia and diarrhea in older children worldwide[22]. All these unfavorable preventable conditions may, to some extent, be associated with poor nutritional status. A Chinese systematic analysis study demonstrated that the combination of several determinants, such as the socioeconomic development, improvement of health care system and policy, the promotion of maternal education and the implementation of other health intervention, accelerated the success of reducing its under-five mortality rate from 64.6 to 20.6 per 1 000 live births and achieving the fourth United Nation’s Millennium Development Goal (MDG-4) nine years ahead of target[23]. Our study results showed inadequate dietary intake and inappropriate eating habits were the most likely causes for childhood malnutrition, and the socioeconomic determinants attributed more to malnutrition than the unchangeable demographic factors, such as the ethnicity or gender. Consequently, health intervention regarding to reduce the malnutrition and child mortality rates in rural areas should focus more on regular growth check, education and consultation rather than food or financial aids alone.

4.4. Study limitations

FFQ is a valid dietary survey tool for evaluating food intake characteristics in individuals and groups, and to provide the means for studying the association of certain dietary patterns with health problems. We used the FFQ method to survey children’s diet in rural Lingshui and chose one typical local food in each category of food for the calculation of caloric and nutrients intakes. However, the nutrient contents are variable in different foods, especially the vitamin contents in vegetables and fruits. For example, we chose cucumber, which is one of the most commonly consumed vegetables in rural Lingshui, as the represent of vegetables and fruits, but it may lead to discrepancy between the calculated vitamin C and β-carotene intake values and the actual total intake values resulting from the consumption of other vegetables and fruits in children. Despite of the calculation bias, FFQ is still a scientific and relatively accurate dietary survey method in the field of the dietary nutrient intake assessment and the study of dietary structure[24],[25]. The sample size may be another limitation of our study; however, this provides a foundation for research targeting rural malnourished children in Hainan, with these study results providing the essential and valuable database for further lager-scaled studies and interventions in the future.

Low intakes of calory, protein, vitamins and minerals are the dietary factors resulting in childhood malnutrition. Low education level of mother, more children in one family, absence of independent eating habit and long dining time (≥20 min) were the identified determinants of malnutrition condition. With the rapid socioeconomic development of China in recent decades, the family incomes, ethnicity, gender and birth order of a child are not detected as determinants of childhood malnutrition in the study area. Our study results indicated that inadequate dietary intake, lower socioeconomic status and inappropriate eating habits were the major determinants to childhood malnutrition, and nutritional intervention focusing on education and behavior change are warranted to help reduce the rate of malnourishment among the children of rural families in south China.

Conflict of interest statement

The authors claim there is no conflict of interest.

Authors’ contributions

Zhang F conceptualized and contributed to the manuscript drafting, as the first author and corresponding author. Lee YCA and Yi C contributed to the data collection and manuscript revision. Alder SC contributed to the study design and manuscript revision. Lin GT and He LM contributed to data analysis.

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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