Public Health Nutrition: 14(5), 896–903
Lack of dietary diversity and dyslipidaemia among stunted
overweight children: the 2002 China National Nutrition and
Yanping Li1,2,*, Nicole M Wedick2, Jianqiang Lai1, Yuna He1, Xiaoqi Hu1, Ailing Liu1,
Songming Du1, Jian Zhang1, Xiaoguang Yang1, Chunming Chen4, Frank B Hu2,3,* and
1National Institute for Nutrition and Food Safety, Chinese Center for Disease Control and Prevention, Nanwei
Road 29 Hao, Beijing 100050, People’s Republic of China:2Departments of Nutrition and Epidemiology,
Harvard School of Public Health, 665 Huntington Avenue, Boston, MA 02115, USA:3Channing Laboratory,
Department of Medicine, Brigham and Women’s Hospital, and Harvard Medical School, Boston, MA, USA:
4Chinese Center for Disease Control and Prevention, Beijing, People’s Republic of China
Submitted 14 March 2010: Accepted 28 September 2010: First published online 10 February 2011
Objective: Both stunting and overweight are present in children across China.
Seemingly paradoxical, these two conditions can also coexist in the same child.
The aim was to examine the associations between dietary food/nutrient intake
and plasma lipid profiles related to stunting and overweight status.
Design: The 2002 China National Nutrition and Health Survey was a family-based
nationally representative cross-sectional study.
Setting: Thirty-one provinces, autonomous regions and municipalities.
Subjects: The study included 13770 children aged 2–17 years. The sample size for
the four exposure groups was 10814 for children of normal height and weight,
2128 for stunted, 729 for overweight and 99 for stunted overweight.
Results: Compared with children of normal height and weight, stunted and
stunted overweight children consumed more high-energy-dense foods with a
lower dietary diversity score, less protein, polyunsaturated fat and Fe, and a
higher molar ratio of phytate to Ca. On the contrary, overweight children tended
to consume significantly less carbohydrates and more protein and fat. Overall,
stunted overweight children consumed lower amounts of vegetables, fruit, white
meat (poultry and fish) and more milk. The OR for prevalent dyslipidaemia were
1?32 (95% CI 1?13, 1?53), 1?76 (95% CI 1?48, 2?09) and 2?59 (95% CI 1?65, 4?07)
among stunted, overweight and stunted overweight children, respectively, com-
pared with children of normal height and weight. In addition, being overweight
was significantly associated with high glucose concentrations, whereas stunting
was significantly associated with having anaemia.
Conclusions: Limited dietary diversity and intake of high-energy-dense foods
were notably observed among stunted overweight children. Furthermore, being
stunted and/or overweight was associated with an increased likelihood of
unhealthy lipid profiles.
The concurrence of under- and overnutrition in children
has been reported in many developing countries, espe-
cially in countries experiencing economic and nutrition
transitions(1,2). In rural areas, stunting remains a major
problem, whereas in metropolitan environs, changes in
income and eating practices may lead to obesity(3,4).
Despite this geographic contrast, stunting and overweight
can coexist in the same family(2), and in the same child(5).
In China, 2?8 million children were stunted and over-
weight in 2002. In poor rural areas, stunting was found in
approximately half of the overweight children younger
than 5 years and in one out of every four overweight
children aged 5–19 years(5).
Childhood stunting is strongly associated with the fol-
lowing events in adulthood: shorter height, less educa-
tion, reduced economic productivity, increased risk of
death and disability-adjusted life-years(6–8). Many studies
have shown that obese children are more likely to become
overweight or obese adults, and to be at increased risk
for developing psychological disorders, asthma, certain
*Corresponding author: Email firstname.lastname@example.org, email@example.com, firstname.lastname@example.org
r The Authors 2011
cancers, CVD, type 2 diabetes and death in adult-
hood(9–12). Stunting, together with obesity in the same
child, may increase the risk of not only stunting-related
diseases but also obesity-related comorbidities.
Impaired fat metabolism among stunted children has
been suggested as a potential mechanism that may increase
the risk of obesity and other related metabolic disorders in
this group(13–15). Energy intake per kilogram body weight(14)
and fasting respiratory quotient(16)measurements were sig-
nificantly higher in stunted children, whereas resting meta-
bolic rate(13)and fasting fat oxidation(16)measurements were
significantly lower. These factors may contribute to obesity
in stunted children.
A paucity of data for food and nutrient intake among
stunted overweight children in China has been reported
to date. Thus, using data from the 2002 China National
Nutrition and Health Survey (CNNHS), our first research
objective was to investigate the associations of dietary
intake among four mutually exclusive groups of children:
normal height and weight, stunted, overweight and
stunted overweight. In addition, we sought to determine
whether dietary patterns of stunted overweight children
differed from those of only stunted or overweight chil-
dren. Moreover, we compared the prevalence of dyslipid-
aemia, high blood glucose and anaemia among the four
groups of children. The final aim of our study was to offer
suggestions for informing and guiding public health
initiatives to ameliorate stunting and overweight among
Chinese children, as well as among children in other
developing countries with similar phenomena.
The study included 13770 children aged 2–17 years with
data from the cross-sectional 2002 CNNHS, which
encompassed thirty-one provinces, autonomous regions
and municipalities directly affiliated with the Central
Chinese Government (Hong Kong, Macao and Taiwan
were not included). A multi-step cluster sampling method
was used. Detailed information about sampling has been
Participants went to the study sites to have their anthro-
pometric measurements taken. In the morning, body
weight was measured to the nearest 0?1kg using a bal-
ance-beam scale (Liaoning, China). Height was measured
to the nearest 0?1cm by a free-standing stadiometer
mounted on a rigid tripod. All trained investigators fol-
lowed standard protocols. The scale and stadiometer
were calibrated at least twice daily (once before the sur-
vey and other calibrations during the conduct of the
survey). In order to estimate reproducibility, body weight
of 2396 participants and height of 2418 participants
(randomly selected from different study sites) of CNNHS
2002 were measured twice by different investigators.
The duplicate measurements in subgroups showed very
high reproducibility (correlation coefficients of duplicate
measurements were 0?98 for weight and 0?99 for height).
BMI was calculated as the participant’s weight in kilo-
grams divided by the square of their height in metres and
expressed as kg/m2. The height and BMI Z-scores, based
on age and sex, were calculated according to the method
recommended by WHO(18), using the WHO child growth
standards for children aged 2–5 years(19)and the WHO
growth reference for children aged 5–17 years(20).
Assessment of nutrient, food and dietary diversity
Trained interviewers visited the participants’ homes daily
for three consecutive days (two weekdays and one
weekend day) and interviewed them in person about
food intake in the last 24h using the dietary recall method.
The interviewers weighed the cooking oil and condiment
consumption of all family members during the 3d. The
child and their main caregiver were interviewed together
to recall the food consumed in the last 24h. The percen-
tage of oil and condiments that the child consumed was
calculated as the ratio of the child’s energy intake divided
by the energy intake of all family members. The energy
and nutrient intakes were calculated using data from the
China Food Composition Table(21). The energy density of
the diet (kJ/g) was calculated as the average energy intake
(kJ) divided by the average food weight (g) per day; all
beverages except water were included in the food weight
calculation(22). Owing to the lack of data on phytate in
the China Food Composition Table(21), we measured the
phytate content of food samples in our laboratory(23). A
validation study indicated that the correlation coefficients
of food intakes between the weighed food method and
the 3d dietary history method ranged from 0?58 to 0?88.
The relative differences in food intakes investigated by the
weighed food method and the 3d dietary history method
were ,10% for most food items(24).
Using a method developed for Chinese populations by
Stookey et al.(25), a dietary diversity score was calculated
for thirteen sub-categories derived from the four main
food groups (i.e. cereals and tubers; animal foods; beans
and dairy products; and vegetables and fruit). For each
sub-category, points were allocated for at least 25g of
consumption of the particular food(26,27). The thirteen
sub-categories included the following: four categories of
‘cereals and tubers’ (rice and products (0?5), wheat and
products (0?5), corn, coarse grains and products (0?5)
and starchy roots and products (0?5)); four categories of
‘animal foods’ (red meat and products (0?5), poultry and
game (0?5), egg (0?5) and fish and shellfish (0?5)); two
categories of ‘beans and dairy products’ (legumes and
products (1?0) and milk and dairy products (1?0)); and
three categories of ‘vegetables and fruit’ (dark-coloured
vegetables (1?5), light-coloured vegetables (1?0) and fruit
Double burden of nutrition of Chinese children 897
(1?5))(25,26). The numbers in brackets indicate point allo-
cation for the corresponding category(26). The total diet-
ary diversity score was calculated by summing points
across all categories with values ranging from 0 to 10 (the
highest dietary diversity).
We used an isoenergetic substitution model(28)to frame
the findings of the study in the context of public health
recommendations for designing prevention strategies of
stunting and overweight among children. Given the daily
energy requirements, total energy intake was held con-
stant and various macronutrients were substituted for
others (e.g. replacing 5% of carbohydrate intake with
The present study was approved by the Ethics Com-
mittee of the National Institute for Nutrition and Food
Safety within the Chinese Center for Disease Control and
Prevention. Signed consent forms were obtained from
both parents or guardians, and from the children them-
selves if they could write.
Blood sample measurements
Plasma glucose levels were measured using a spectro-
photometer within 4h after a night’s fasting blood sample
was drawn. Plasma total cholesterol (TC), TAG and HDL
cholesterol (HDL-C) were measured enzymatically with
the Hitachi 7060, 7180 autoanalyser (Hitachi, Tokyo,
Japan). LDL cholesterol (LDL-C) was calculated by means
of standard methods. Plasma Hb was determined by the
Anaemia was defined by the Hb cut-off points recom-
mended in 2001 by WHO and the UNICEF. The cut-off
points (g/l) were 110, 115, 120, 120 and 130 for children
aged ,5, 5–11, 12–14, $15 years (boys) and $15 years
On the basis of age and sex, values for TAG, TC, LDL-C
and glucose above the 90th percentile(29)of the present
sample were considered as abnormally high, whereas
values for HDL-C below the 10th percentile(29)were
considered as abnormally low. Dyslipidaemia was defined
as having at least one abnormal TC, TAG or HDL-C value.
On the basis of height and BMI Z-scores, children
were classified into four groups: (i) normal height and
weight, height Z-score $22 SD and BMI Z-score #1 SD;
(ii) stunted, height Z-score ,–2 SD and BMI Z-score #1 SD;
(iii) overweight, height Z-score $22 SD and BMI Z-score
.1 SD; (iv) stunted overweight, height Z-score ,22 SD
and BMI Z-score .1 SD.
Means and standard errors for energy, nutrient and
food intakes consumed by the four groups of children
were computed using a generalized linear model adjust-
ing for age category (#5, 6–12 and 13–19 years), sex
and urban v. rural. For these cross-sectional data, OR
for prevalent dyslipidaemia, high glucose and anaemia
among stunted and/or overweight children compared
with children of normal height and weight were analysed
using multivariate logistic regression. Statistical interac-
tions between stunting and weight status for dyslipidae-
mia, high glucose and anaemia were conducted using
likelihood ratio tests. A sensitivity analysis was performed
using the 95th percentiles of TAG and TC, and 5th per-
centile of HDL-C, to indicate dyslipidaemia.
Using isoenergetic substitution models, the odds of
replacing one dietary macronutrient with another for the
same amount of energy contribution were estimated(28).
Polychotomous logistic regression was used to calculate
the odds of stunting, overweight and stunted overweight,
with normal height and weight as the reference category.
Among the 13770 participants, 63% had complete
data for the height measurements of both parents. A
sensitivity analysis using this subset was performed to
examine whether the association of dyslipidaemia with
stunting and overweight was explained by the potential
effect of parents’ height. As socio-economic status was
associated not only with lipid metabolism, stunting and
overweight but also with food and nutrient consumption,
we performed an additional sensitivity adjusting for socio-
economic status as determined by family income and
mother’s educational level. Statistical significance was
defined at an a level of 0?05. The SAS statistical software
package version 9?2 (SAS Institute Inc., Cary, NC, USA)
was used for all statistical analyses.
The proportion of children who were of normal height
and weight, as well as stunted, overweight and stunted
overweight, was 78?5, 15?5, 5?3 and 0?7%, respectively
(Table 1). Among rural areas, the prevalence of being
stunted was significantly higher, whereas in urban areas
the prevalence of being overweight was significantly
higher (x25397?02, P,0?0001).
Compared with children of normal height and weight,
energy intake was significantly lower among stunted chil-
dren and significantly higher among overweight children.
The energy intake of stunted overweight children was
significantly lower than that of overweight children, but not
different from that of normal or stunted children (Table 1).
After further adjustment for socio-economic status, only
overweight children were found to consume significantly
higher dietary energy. Overall, stunted and stunted over-
weight children consumed significantly less protein, poly-
unsaturated fat, Fe and Se, and their diet had a significantly
higher energy density (kJ/g) and higher molar ratio of
phytate to Ca (Table 2). On the contrary, overweight chil-
dren tended to consume significantly less carbohydrates and
more protein and fat.
Table 3 shows the results by group for consumption of
various foods. Overall, stunted overweight children tended
to consume lower amounts of vegetables, fruit, white
898Y Li et al.
meat (poultry and fish) and more milk, but these asso-
ciations did not reach statistical significance. The dietary
diversity scores for stunted and stunted overweight chil-
dren were significantly lower than the scores for normal
and overweight children. Specifically, the dietary diversity
scores for vegetables/fruit and animal food groups for
stunted and stunted overweight children were significantly
lower than those for normal and overweight children; the
cereal and tubers consumed by stunted overweight chil-
dren had a significantly higher dietary variety score than
those consumed by stunted children. Further adjustment
for socio-economic status did not significantly attenuate
Using an isoenergetic substitution model(24), we observed
in rural areas that for each 5% energy from carbohydrates
substituted by protein, the odds of being stunted and
stunted overweight decreased by 32% (OR50?68, 95% CI
0?46, 0?99) and 19% (11–25%), respectively, whereas the
odds of being overweight increased by 29% (10–52%).
When 2% of energy from carbohydrates was substituted by
polyunsaturated fat, the odds of being stunted overweight
decreased by 34% (30–37%), whereas the odds of being
overweight increased by 24% (15–23%). However, in urban
areas, when 5% of energy from fats was substituted by
carbohydrates, the odds of being overweight decreased by
Both stunted and overweight children had greater odds
for having an unhealthy lipid profile, with the strongest
odds being observed among stunted overweight children.
Compared with children of normal height and weight, the
OR for prevalent dyslipidaemia were 1?32 (95% CI 1?13,
1?53), 1?76 (95% CI 1?48, 2?09) and 2?59 (95% CI 1?65,
4?07) among stunted, overweight and stunted overweight
children, respectively (Fig. 1). After further adjustment for
parents’ height, income and educational level, the odds of
dyslipidaemia among stunted overweight children were
Table 1 Characteristics of the study population: China National Nutrition and Health Survey 2002
Normal height and weight Stunted Overweight Stunted overweight
1081478?5 2128 15?5 7295?3 990?7
Table 2 Comparison of energy and nutrient intakes: China National Nutrition and Health Survey 2002
Normal height and
weight (n 10814)
Energy intake (MJ)*
Energy density of diet (kJ/g food)-
Carbohydrate (% energy)*
Protein (% energy)*
Protein (% energy ,10%)--
Fat (% energy)*
Molar ratio of phytate to Ca
a,b,c,dMean values within a row with unlike superscript letters were significantly different (P,0?05).
*Means and SE from generalized linear models adjusted for age category, sex and urban/rural.
-Daily energy adjusted.
--Logistic regression model, adjusted for age category, sex and urban/rural.
Double burden of nutrition of Chinese children899
3?6 (95% CI 2?0, 6?6). Applying a more conservative
definition of dyslipidaemia (i.e. serum lipid concentra-
tions above the 95th percentile for TAG and TC or below
the 5th percentile for HDL-C as abnormal), the odds of
dyslipidaemia among stunted overweight children were
higher (4?2, 95% CI 2?1, 8?2). Being overweight was
significantly associated with a greater odds of having an
abnormally high glucose level (Fig. 2), whereas being
stunted was significantly associated with being anaemic
(Fig. 3). We did not find evidence of significant interac-
tions between stunting and body weight for dyslipidaemia,
high glucose or anaemia.
Findings from the present study suggest that a lack of
dietary diversity and high-energy-dense diets may be
Table 3 Comparison of food consumption: China National Nutrition and Health Survey 2002
Normal height and weight (n 10814)
Stunted (n 2128)
Overweight (n 729)
Stunted overweight (n 99)
Cooking oil (g/4?2MJ)
Red meat (g/4?2MJ)
White meat (poultry and fish, g/4?2MJ)
Dietary diversity score
Cereals and tubers
Vegetables and fruit
Beans and dairy products
a,b,c,dMean values within a row with unlike superscript letters were significantly different (P,0?05).
Means and SE from generalized linear models adjusted for age category, sex and urban/rural.
Dietary diversity score was calculated using thirteen sub-categories derived from the four main food groups (details are provided in the Methods section).
Fig. 1 OR for prevalent dyslipidaemia according to stunting
and weight status: China National Nutrition and Health Survey
2002. On the basis of age and sex, values for TAG and total
cholesterol above the 90th percentile were considered as
abnormally high, whereas values for HDL cholesterol below
the 10th percentile were considered as abnormally low.
Dyslipidaemia was defined as having at least one abnormal
TAG, total cholesterol or HDL cholesterol value (P trend for
weight5,0?0001; P trend for stunting5,0?0001; P for
Fig. 2 OR for prevalent high glucose concentrations according
to stunting and weight status: China National Nutrition and
Health Survey 2002. High glucose was defined as having a
fasting plasma glucose value above the age- and sex-specific
90th percentile (P trend for weight5,0?0009; P trend for
stunting50?1824; P for interaction50?6219)
900Y Li et al.
related to a child being both stunted and overweight.
Stunted overweight children consumed less protein,
polyunsaturated fat, Fe, Se and bioavailable Ca. Both
stunted and overweight children had greater odds of
having dyslipidaemia than children of normal height and
In developing countries, there were 559 million chil-
dren younger than 5 years; among them, 156 million were
stunted(30). Protein and energy deficiency were initially
evaluated as major causes of stunting. However, with
improved socio-economic development and continued
food supply abundance, stunting rather than underweight
remained the most prevalent problem(31,32). At the end of
the last century, among children younger than 5 years in
China, Egypt and Mexico, the prevalence of underweight
was 10?0, 4?0 and 7?5%, respectively, whereas the pre-
valence of stunting was 14?2, 18?7 and 17?7%, respec-
tively(32). The present study suggests that, in addition to
lower protein intake, stunted and stunted overweight
children also consume less polyunsaturated fat, Se, Fe
and bioavailable Ca. Inadequate intake of these nutrients
may compromise optimal linear growth. These observa-
tions are consistent with previous observational and
based on energy – protein supplements to ameliorate
stunting in thirty-six countries, reduced the prevalence of
stunting at 36 months by only 0?3%, whereas the micro-
nutrient interventions reduced stunting by 17?4%(34).
One potential mechanism may involve impaired fat
metabolism among stunted overweight children. After
measuring the energy metabolism of stunted children,
Grillol and Hoffman found that the resting metabolic
rate(13)and fasting fat oxidation(16)were significantly
lower. In the follow-up period, these stunted children had
a higher rate of weight gain concurrent with decreased
lean mass(13). Severe childhood stunting was also found
to be associated with greater central adiposity in Guate-
malan adults(36). In the present study, stunted children
had higher levels of TAG, TC and LDL-C and lower levels
of HDL-C. Unfavourable lipid profiles among stunted
children could be a potential mechanism underlying the
increased risk of CVD in shorter men and women(37).
Childhood obesity has been noted as a major determinant
of adverse plasma lipids in childhood, and also as a
predictor of CVD, certain cancers, type 2 diabetes, asthma
and death in adulthood(9–12). Research has seldom stu-
died the simultaneous effects of both stunting and over-
weight on the health of the same child. Barker et al.(7,37)
reported that not only shorter childhood height but also
accelerated childhood weight gain was associated with an
increased risk of CVD in adulthood. Consistently, we
observed that the strongest significant association for
dyslipidaemia was among stunted overweight children.
In the present study, stunted and stunted overweight
children had less dietary diversity overall, especially
among vegetables/fruit and animal food groups. Stunted
overweight children consumed significantly more wheat
flour products and milk than stunted children. In China,
reduced-fat milk is scarce and relatively expensive com-
pared with full-fat milk. It is plausible that additional
energy intake from full-fat dairy and refined wheat flour
products, and lower consumption of a variety of vege-
tables and fruits, may contribute to the existence of
stunting and overweight in the same child. As Chinese
diets are still based on plant foods, the energy density of
these diets depends relatively more on cereals, which
contribute to 40% of total foods and 50% of energy(38). In
this large nationally representative study population,
stunted children consumed more vegetables, but along
with a high consumption of rice and rice products and
low consumption of fruit. Substituting energy from car-
bohydrates with protein in poor rural areas should be
considered for prevention of stunting, whereas sub-
stituting energy from fat with carbohydrates, especially
replacing saturated fat with carbohydrates with low gly-
caemic index(39), should be considered for prevention of
obesity in urban areas.
The strengths of our study include the large sample
size, which facilitated the comparison between the four
groups of children, as well as detailed information from
3d dietary recall. An additional strength is the availability
of biological data for this large sample of participants.
Both dietary data and blood samples are generally diffi-
cult to obtain from children and adolescents.
One primary limitation of the present study is the cross-
sectional design that disallows a sequence of temporality
to be established for stunted overweight and dietary
patterns or prevalent dyslipidaemia. For example, reverse
causation may be present whereby stunted overweight
children may have changed their dietary patterns in an
attempt to control body weight or stimulate height
development when assessed at the time of the 2002
Fig. 3 OR for prevalent anaemia according to stunting and
weight status: China National Nutrition and Health Survey
2002. Anaemia was defined by the Hb cut-off points
recommended in 2001 by WHO and UNICEF. The cut-off
points (g/l) were 110, 115, 120, 120 and 130 for children aged
,5, 5–11, 12–14, $15 years (boys) and $15 years (girls),
respectively (P trend for weight50?0049; P trend for stunt-
ing5,0?0001; P for interaction50?6512)
Double burden of nutrition of Chinese children901
CNNHS. Future prospective investigations are warranted
to clarify the findings herein. Another limitation is that we
had no documentation on infectious diseases, which may
be related to both stunting and micronutrient deficiency.
Safe food and drinking water, micronutrient supple-
mentation and food fortification were other potential
confounding factors that should be considered in future
Preventing both stunting and overweight simultaneously
in the same population will be a remarkable public health
challenge, as providing adequate food to prevent stunting
may in turn enable an obesogenic environment(31). Simi-
larly challenging, obesity prevention programmes should
not lose sight of efforts to combat malnourishment. In a
concerted effort to promote optimal growth in all children,
malnutrition and obesity prevention programmes should
collaborate with each other in countries where under- and
overnutrition coexist. Monitoring height-for-age and
weight-for-height is necessary for both programmes to
identify stunted overweight children(31). Considering the
long-term health burden of childhood stunting and over-
weight, the earlier and more effectively these conditions are
treated, the greater the opportunity for recovery, or, at a
minimum, the attenuation of future health consequences.
The 2002 China National Nutrition and Health Survey
was supported by the Ministry of Health and the Ministry
2001DEA30035 and 2003DIA6N008). The authors declare
that they have no conflict of interest. Y.L. was also a
Takemi fellow in the Department of Global Health and
Population at Harvard School of Public Health. All authors
contributed to the discussion and interpretation of the data
and to the writing of the manuscript. X.Y., C.C. and G.M.
were the main investigators of the 2002 CNNHS. The
analyses were performed primarily by Y.L. and N.M.W.
The present study was initiated by C.C., and later con-
ceptualized and supervised by F.B.H. The authors
graciously thank all team members and participants from
the thirty-one provinces. They appreciate the support
of UNICEF, WHO, Unilever and the Danone Nutrition
in China(Grant no.
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