Prevalence, Demographic Characteristics and Associated Risk Factors of Malnutrition Among 0-5 Aged Children: A Cross-Sectional Study From Van, Eastern Turkey

Abstract

Malnutrition in childhood is a dramatic indicator of poor socio-economical status worldwide. To recognize and reveal the socio-demographic features is crucial, especially for developing countries. Our aim was to investigate the prevalence and association with sociodemographic variables of malnutrition in 0-5 years old children in Van, Turkey. A total of 702 children are included in this cross-sectional study. Demographic features of subject including age, gender, family characteristics and other data were obtained. Nutritional assessment was done using anthropometric indices including weight-for-age, height-for-age, weight-for-height, head circumference and body mass index-for-age. Multivariate logistic regressions were carried out to assess malnutrition- associated factors. Prevalence of underweight, stunting and wasting were 19.7, 17.7 and 16.2%, respectively. Socio-demographic variables that statistical significantly in association with malnutrition were low monthly family income, educational level and employment status of father, parental consanguinity, number of pregnancies, regular intake of vitamin D and history of prematurity. The prevalence of children with head circumference-z score ≤−2SD and body mass index-for-age ≤−2SD were 9.8 and 16.3%, respectively. Multivariate analysis detected following risk factors for these indices; low monthly family income, history of prematurity, unemployed father and the period between pregnancies (1- 2 years). We found that prevalence of malnutrition in the city of Van, was still higher than more developed regions of Turkey. The associated risk factors of malnutrition should be specifically interpreted by health professionals and also by government authorities that are responsible for making practical politics of public health.

Full text

[Pediatric Reports 2016; 8:6112] [page 15]
Prevalence, demographic
characteristics and associated
risk factors of malnutrition
among 0-5 aged children:
a cross-sectional study
from Van, eastern Turkey
Baran Serdar Kizilyildiz,1
Bülent Sönmez,2Kamuran Karaman,3
Burhan Beger,4Adnan Mercen,1
Süleyman Alioğlu,1Yaşar Cesur5
1Department of Pediatrics, Private
Kiziltepe Ipekyolu Hospital, Mardin;
2Department of Pediatrics, Private
Istanbul Hospital; 3Department of
Pediatrics, 4Department of Pediatric
Surgery, 5Department of Pediatric
Endocrinology, Faculty of Medicine,
Yüzüncü Yil University,Van, Turkey
Abstract
Malnutrition in childhood is a dramatic indi-
cator of poor socio-economical status world-
wide. To recognize and reveal the socio-demo-
graphic features is crucial, especially for devel-
oping countries. Our aim was to investigate
the prevalence and association with socio-
demographic variables of malnutrition in 0-5
years old children in Van, Turkey. A total of 702
children are included in this cross-sectional
study. Demographic features of subject includ-
ing age, gender, family characteristics and
other data were obtained. Nutritional assess-
ment was done using anthropometric indices
including weight-for-age, height-for-age,
weight-for-height, head circumference and
body mass index-for-age. Multivariate logistic
regressions were carried out to assess malnu-
trition-associated factors. Prevalence of under-
weight, stunting and wasting were 19.7, 17.7
and 16.2%, respectively. Socio-demographic
variables that statistical significantly in asso-
ciation with malnutrition were low monthly
family income, educational level and employ-
ment status of father, parental consanguinity,
number of pregnancies, regular intake of vita-
min D and history of prematurity. The preva-
lence of children with head circumference-z
score ≤−2SD and body mass index-for-age
≤−2SD were 9.8 and 16.3%, respectively.
Multivariate analysis detected following risk
factors for these indices; low monthly family
income, history of prematurity, unemployed
father and the period between pregnancies (1-
2 years). We found that prevalence of malnu-
trition in the city of Van, was still higher than
more developed regions of Turkey. The associ-
ated risk factors of malnutrition should be
specifically interpreted by health professionals
and also by government authorities that are
responsible for making practical politics of
public health.
Introduction
Pediatric malnutrition is a major public
health problem worldwide and globally a major
contributive factor to nearly 45% of all mortali-
ty in childhood.1-3 Deficits of protein, energy
and micronutrients together with environmen-
tal, behavioral, biological and health-care serv-
ice related factors lead to growth failure, devel-
opment delay and other worse outcomes.1,3,4
Malnutrition is a chronic and extensive situa-
tion, difficult to cope typical of developing
countries. On the other hand, it is usually a
result of acute or chronic diseases in devel-
oped countries.1 So, as generally accepted, it
can be said that the physical growth of infants
and children is an indicator of health and well-
ness.5Assessment of pediatric malnutrition is
based on objective anthropometric measure-
ments such as Z-score, weight-for-height
(wasting index), height-for-age (stunting
index), weight-for-age (underweight index),
head circumference, body mass index, mid–
upper arm circumference and skin fold thick-
ness. However it is difficult to determine mal-
nutrition in childhood with a single index.3,6
Recently, World Health Organization (WHO)
recommended new growth standards for chil-
dren under 5 years and attached more indica-
tors (e.g. body mass index for age) to describe
optimal early childhood growth.7 In addition,
several investigations have been performed for
testing the WHO charts in different countries,
which have showed disagreements in preva-
lence compared with existing standards, the
WHO standards generally accepted for clinical
assessment of malnutrition in children world-
wide.5
Few studies have been published concern-
ing malnutrition prevalence from Eastern
Turkey, but there is a lack of data including
sociodemograhic features. This paper presents
recent status of malnutrition in children from
Van province.
Materials and Methods
This cross-sectional study was carried out
between December 2009 and February 2010 in
Van city. Van province is located at the Eastern
border of Turkey, neighbouring Iran. This
province is the most undeveloped region of the
country in respect of socioeconomical and
demograhic features as mentioned in report of
Turkey Demographic and Health Survey,
Hacettepe University Institute of Population
Studies, 2008. Estimated total population of
children under 5-year old was 42,730. The size
of sample population to calculate prevalance
was determined by using n=X2*N*P*[ME2*/
(N-1)]+[X2*P*(1-P)], n=sample size, X2=Chi-
square for the specified confidence level at 1
degree of freedom, N=population size, P=popu-
lation proportion and ME=desired margin of
error formula. Subjects with incomplete ques-
tionnaire and absent anthropometric meas-
ures were excluded. Subjects with a previous
chronic disease and cerebral palsy were also
excluded. A total of 702 children were enrolled
in the study. Selection of samples based on
data revealed from 17 public health centers
that located in socio-economically different
districts of Van city. An informed consent from
the mother or legal caregiver was obtained to
collect socio-demographic information by
using a standardized form. All children were
measured and weighed according to standard
procedures by the same interviewer.
Standing height was measured in over 2
years old children using a portable
adult/infant-measuring unit mountable to wall
with an accuracy of 0.1 cm. The height of chil-
dren under 2 years of age was measured in
supine position with a measuring board.
Weight was measured by infant scale with an
accuracy of 10 g in 0-24 month-aged and a by
ground scale with an accuracy of 100 g in over
2 years old. The measurement of head circum-
ference was performed using a nonstretchable
Pediatric Reports 2016; volume 8:6112
Correspondence: Baran Serdar Kizilyildiz,
Hafiziye Mah. Türközü Sok Elçioğlu Sitesi B-blok
No:17, Van, Turkey.
Tel.: +90.432.2178101.
E-mail: baranserdar@hotmail.com
Key words: Turkey; prevalence; malnutrition;
wasting syndrome; thinness.
Contributions: BSK and BS wrote the paper; KK,
BB, AM and SA have collected the data, performed
statistical analysis and reviewed the literature;
YC revised the article.
Conflict of interest: the authors declare no poten-
tial conflict of interest.
Received for publication: 15 July 2015.
Revision received: 26 April 2016.
Accepted for publication: 27 April 2016.
This work is licensed under a Creative Commons
Attribution NonCommercial 4.0 License (CC BY-
NC 4.0).
©Copyright B.S. Kizilyildiz et al., 2016
Licensee PAGEPress, Italy
Pediatric Reports 2016; 8:6112
doi:10.4081/pr.2016.6112

[page 16] [Pediatric Reports 2016; 8:6112]
plastic-coated tape placed superior to the
supraorbital ridge and adjusted around the
occiput. Body mass index was calculated using
weight in kilograms that divided by the square
of height in meters. Z-Scores for weight-for-
height, height-for-age and weight-for-age were
calculated using WHO growth standards for
spesific age groups.
Wasting, stunting and underweight were
defined as z-scores≤−2 for weight-for-height,
height-for-age and weight-for-age, respective-
ly. Z-scores for body-mass index and head cir-
cumference were calculated and malnutrition
was defined if z-scores found under −2.
Independent variables such as age, gender,
and history of prematurity were listed in
Tables 1-3. Socio-economical status was deter-
mined by monthly income of each subject’s
family using Turkish Statistical Institute data.
Monthly income under 750 TL, 750-1500 TL
and above 1500 TL considered as low, interme-
diate and high family income, respectively.
Subjects, who took daily 400 U vitamin D regu-
larly, were considered sufficent for statistical
analysis.
SPSS (Statistical Package for Social
Sciences) for Windows 15.0 was used for sta-
tistically analysis. Multivariate regression
analysis was used to determine the risk factors
of malnutrition. Results evaluated in confi-
dence interval as 95% and a P-value of 0.05 was
considered statistically significant.
Results
Our study included a total of 702 children,
371 were male and age groups were as follows:
0-5 months (n=192), 6-11 months (n=123),
12-23 months (n=142), 24-35 months (n=81),
36-47 months (n=61) and 48-60 months
(n=103). According to socio-economical status;
153 subjects were in low, 329 in intermediate
and 220 in high-level groups. Our results
revealed that overall prevalence of under-
weight, stunting and wasting were 19.7%
(n=138), 17.7% (n=124) and 16.2% (n=114),
respectively. No significant relationship was
seen between gender and these variables. The
rate of underweight, stunting and wasting
were highest at 0-5 month-old group. The
prevalence of children with head circumfer-
ence-z score ≤-2SD and body mass index-for-
age ≤-2SD were 9.8% (n=69) and 16.3%
(n=115), respectively. Concerning all anthro-
pometric indices, the number of male subjects
who had malnutrition was higher than females
but the difference was not statistically signifi-
cant (Table 1). Prevalence of malnutrition
among children, according to various socio
demographic factors, has been showed in
Table 2.
Logistic regression analysis revealed that
wasting was statistically significant in associ-
ation with low socio-economical status, educa-
tional level of father and employment status of
father. Also, the risk of underweight among
children with the following features was more
likely than children without them: history of
prematurity, low monthly family income, sec-
ond-degree parent consanguinity and educa-
tional level of father. Regarding stunting, sub-
jects who did not use vitamin D regularly, were
2.4 times [adjusted odd ratio (AOR)=2.4, 95%
confidence interval (CI): 1.2-5.1] more likely
to be stunted than children who did not use.
Other variables that significantly associated
with stunting were low monthly family income,
history of prematurity and employment status
of father (Table 3).
In logistic regression analysis, head circum-
ference values were significantly low in chil-
dren with history of prematurity, low monthly
family income and unemployed father.
Malnutrition risk, according to body mass
index (BMI), was also statistically significantly
higher among subjects with history of prema-
turity and with unemployed father. This risk
was increased in children whose mother had a
gap of 1-2 years between pregnancies.
There were no significant relationships
between malnutrition and other demographic
factors including number of siblings, birth
order, number of died children and/or abor-
tions, family size, vaccination status, number
of visits of health caregivers, education level,
age and occupation of mother, existence of
family insurance and maternal smoking (data
not shown). Results of the logistic regression
of both anthropometric indexes are shown in
Table 3.
Discussion
In terminology of nutrition disorders exists
a slight confusion. The term, Protein-energy
malnutrition (PEM) has been defined as an
imbalance between the supply of protein and
energy and the body’s demand for them to
ensure optimal growth and function by WHO.4
On the other hand there was no consensus in
defining the terms failure to thrive, failure to
gain weight, undernutrition etc. and absence of
a definite description of these terms results in
underrecognition of prevalance, demograhic
features, relationship with other disorders as
well as outcomes in children.1,3,8 According to
previous terminology, we used malnutrition
(or PEM) term to describe the conditions that
defined as underweight (low weight for age),
stunting (low height for age) and wasting (low
weight for height).4
Like in other developing countries, the mal-
nutrition of children is a major public health
problem in Turkey, especially in our region.
Our results has shown overall prevalence of
underweight, stunting and wasting in children
below 5 years of age to be 19.7, 17.7 and 16.2%,
respectively. These rates were higher than
overall prevalence rates reported from Turkey
Article
Table 1. Distribution of the children with malnutrition according to age and gender.
Variable Total Wasting, Underweight, Stunting, Head circumference, Body mass index-for-age,
weight-for-height weight-for-age height-for-age ≤−2SD (%) ≤−2SD (%)
≤−2SD (%) ≤−2SD (%) ≤−2SD (%)
Age, months
0-5 192 43 (22.3) 49 (25.5) 32 (16.6) 23 (11.9) 48 (25)
6-11 123 24 (19.5) 20 (16.2) 15 (12.1) 7 (5.6) 22 (17.8)
12-23 142 20 (14) 25 (17.6) 23 (16.1) 11 (7.7) 20 (14)
24-35 81 10 (12.3) 18 (22.2) 19 (23.4) 10 (12.3) 8 (9.8)
36-47 61 6 (9.8) 10 (16.3) 18 (29.5) 9 (14.7) 7 (11.4)
48-60 103 11 (10.6) 16 (15.5) 17 (16.5) 9 (8.7) 10 (9.7)
Gender
Female 331 50 (15.1) 56 (16.9) 54 (16.3) 30 (9) 49 (14.8)
Male 371 64 (17.2) 82 (22.1) 70 (18.8) 39 (10.5) 66 (17.7)
P-value* - 0.859 0.390 0.893 0.712 0.434
Total 702 114 (16.2) 138 (19.7) 124 (17.7) 69 (9.8) 115 (16.3)
*P<0.05 was considered significant.

[Pediatric Reports 2016; 8:6112] [page 17]
(underweight 2.8%, stunting 10.3% and wast-
ing 0.9%).9 On the other hand, Aslan et al. have
reported underweight, stunting and wasting
prevalence under 5 years children as 9.4, 23.4
and 4.8%, respectively, in Van region in 2002.10
It can be said that, stunting prevalence has not
been changed significantly during time. We
thought that the distinctions in underweight
and wasting ratios between our study and
Aslan et al. were due to difference of study pop-
ulation and recently increased migration from
rural areas to city center. Similarly, different
prevalence ratios of malnutrition have also
been reported regarding the geographical
regions in Turkey. For example in West
Anatolia, stunting has been reported as 3.3%,
wasting 0.2% and underweight as 1.5%.9 While,
the prevalence was found as 10.9% for stunt-
ing, 4.8% for underweight and 8.2% for wast-
ing in children under five years in Aydin, a
western city of Turkey.11 The infant mortality
rate was 17 and under five mortality rate was
24 per 1000 live births in Turkey while these
ratios were reported as 39 and 50, respectively
in our region.9 These data indicate the low
socio-economical status in our region and
explains why our malnutrition rates were
Article
Table 2. Prevalence of wasting, underweight, stunting, head circumference under −2SD and body mass index-for-age under −2SD according
to various socio demographic factors among the study population.
Variable Category Total Wasting Underweigh Stunting Head circumference, Body mass index-for-age,
(%) (%) (%)
≤−2SD (%) ≤−2SD (%)
History of prematurity Yes 47 14 (29.7) 21 (44.6) 19 (40.4) 14 (29.7) 18 (38.2)
No 655 100
Regular intake of vitamin D Yes 314 35 (11.1) 42 (13.4) 37 (11.8) 24 (7.6) 33 (10.5)
No 388
Vaccination status Partially vaccinated 44 9 (1.4) 14 (2.1) 9 (1.4) 5 (11.3) 12 (27.2)
Fully vaccinated 658
Pregnancy intent Unintended 9 1 (0.14) 1 (0.14) 1 (0.14) 2 (22.2) 2 (22.2)
Intended 693
Monthly family income Low 153 30 (19.6) 40 (26.1) 36 (23.5) 16 (10.4) 31 (20.2)
Intermediate 329 55 (16.7) 70 (21.2) 66 (20) 41 (12.4) 59 (17.9)
High 220 29 (13.1) 29 (13.1) 23 (10.4) 12 (5.4) 25 (11.3)
Number of siblings 1 122 13 (10.6) 16 (13.1) 14 (11.5) 11 (9) 13 (10.6)
2 68 12 (17.6) 17 (25) 14 (20,5) 6 (8.8) 12 (17.6)
3 133 24 (18) 36 (27) 36 (27) 19 (14.2) 24 (18)
>3 203 35 (21.3) 36 (21.9) 34 (20.7) 16 (7.8) 33 (16.2)
Only child 176 30 (17) 35 (19.8) 27 (15.3) 17 (9.6) 33 (18.7)
Birth order First 213 36 (16.9) 40 (18.7) 40 (18.7) 23 (10.7) 38 (17.8)
After first sibling 136 12 (8.8) 17 (12.5) 20 (14.7) 6 (4.4) 8 (5.8)
Last child 353 66 (18.7) 82 (23.2) 65 (18.4) 40 (11.3) 69 (19.5)
Interval between pregnancies <1 year 167 23 (13.7) 33 (19.7) 39 (23.3) 15 (8.9) 21 (12.5)
1-2 year 187 25 (13.3) 28 (14.9) 25 (13.3) 16 (8.5) 26 (13.9)
>2 year 172 26 (15.1) 43 (25) 23 (13.3) 18 (10.4) 30 (17.4)
Crowded family Yes 243 51 (20.9) 63 (25.9) 51 (20.9) 32 (13.1) 59 (24.2)
No 459
Visit of health professionals None 119 56 (47) 71 (59.6) 56 (47) 29 (24.3) 52 (43.6)
to home 1 128 9 (7) 7 (5.4) 5 (3.9) 5 (3.9) 7 (5.4)
2 243 18 (7.4) 21 (8.6) 22 (9) 10 (4.1) 21 (8.6)
3 212 31 (14.6) 40 (18.8) 42 (19.8) 25 (11.7) 35 (16.5)
Social security Present 671 109 (16.2) 133 (19.8) 121 (18) 59 (8.7) 108 (16)
(health insurance) Absent 31 5 (16.1) 6 (19.3) 4 (12.9) 10 (32.2) 7 (22.5)
Educational status of mother Primary or less 349 60 (17.1) 82 (23.4) 70 (20) 44 (12.6) 64 (18.3)
Secondary 235 44 (18.7) 47 (20) 41 (17.4) 22 (9.3) 43 (18.2)
High 87 5 (5.7) 4 (4.6) 4 (4.6) 2 (2.2) 8 (9.1)
University 31 58 (16.1) 6 (19.3) 6 (19.3) 1 (3.2) 0
Employment status of mother Employed 34 5 (14.7) 6 (17.6) 6 (17.6) 1 (2.9) 0
Unemployed (housewife) 668 109 (16.3) 133 (19.9) 119 (17.8) 68 (10.1) 115 (17.2)
Educational status of father Primary or less 99 20 (20.2) 28 (28.2) 25 (25.2) 20 (20.2) 20 (20.2)
Secondary 398 73 (18.3) 88 (22.1) 77 (19.3) 37 (9.2) 76 (19)
High 105 15 (14.2) 17 (16.1) 15 (14.2) 8 (7.6) 14 (13.3)
University 100 6 (6) 6 (6) 8 (8) 4 (4) 4 (4)
Employment status of father Employed 501 69 (13.7) 85 (16.9) 73 (14.5) 40 (7.9) 67 (13.3)
Unemployed 201 45 (22.3) 54 (26.8) 52 (25.8) 29 (14.4) 48 (23.8)
Parental consanguity Present 194 42 (21.6) 53 (27.3) 46 (23.7) 26 (13.4) 38 (19.5)
None 508 72 (14.1) 86 (16.9) 79 (15.5) 43 (8.4) 77 (15.1)
Maternal smoking Yes 112 22 (19.6) 32 (28.5) 26 (23.2) 14 (12.5) 19 (16.9)
No 590 92 (15.5) 107 (18.1) 99 (16.7) 55 (9.3) 96 (16.2)

[page 18] [Pediatric Reports 2016; 8:6112]
higher than mean rates of whole country.
Studies on childhood malnutrition have
been reported mostly from Africa, India and
other third world countries.11 In Bangladesh,
46% of the children under 5 years were under-
weight, 39% were stunted and 28% were wast-
ed.12 A study from Haiti revealed that 14.8% of
children under five were stunted, 15.3% were
wasted, and 16.1% were underweight.13
Manjunath et al. have reported the prevalence
of underweight, stunting and wasting was
60.4, 55.4 and 43%, respectively, in India.14 In
addition, stunting and underweight prevalence
were 44.2 and 19.1%, respectively among 0-36
month-old children in Tanzania.15 These find-
ings are indicating the importance of both eco-
nomical and social development level on
prevalance of malnutrition, worldwide.
We found that low economical status was a
significant risk factor of malnutrition. As men-
tioned before, inadequate and inappropriate
food intake due to poverty is the main underly-
ing cause of malnutrition.4,11,16 Because the
severity and distribution of malnutrition
depends on the political and economic situa-
tion, the level of education and sanitation, pro-
duction and cultural food traditions, the avail-
ability and quality of health services and so in
general monthly income of family is in close
correlation with prevalance of malnutri-
tion.11,16 A study from India has showed that,
there was a twofold increase in undernutrition
among children with low standard households
than among those with high standards.4
Linear growth failure is the most prevalent
form of malnutrition globally in children and
has longer-term impact on both physical, neu-
rodevelopmental and economic capacities.2 In
a wide systematic review concerning trends in
prevalence of stunting among children under 5
years old in 141 developing countries has
revealed a decline in mean prevalence of mod-
erate and severe stunting from 47.2% in 1985
to 29.9% in 2011.17 But as mentioned in the
same study, although anthropometric status of
children has improved during time, there were
significant differences globally across geo-
graphical areas and countries.17 For example,
our stunting ratio (17.7%) was lower than in
Asia (31.3%) but higher than in South America
(13.8%).18 But in Salmas district in Iran, which
is the neighboured region to Van, the preva-
lence of stunting was 7.3% in 2011.6 These
findings indicate the importance of local data
concerning stunting to determine proper
socio-economical politics for improving nutri-
tional status of children.
The highest rates of stunting, underweight
and wasting were in 0-5-month-old group in
our study. Ergin et al. reported that stunting
prevalance was higher in 12-23-month-old
group and they suggested the fact of stopping
breast-feeding earlier than the 24 months and
difficulties in providing adequate and safe food
as a cause of this finding.11 In addition, in a big
cross-sectional study from Iran which consist-
ed of nearly 70,000 children under 5 years of
age, has shown that the highest rate of both
stunting, underweight and wasting were
observed at 48-59-months-age group and the
authors have mentioned that high rate of
breastfeeding among Iranian infants could
result in low prevalence rates of malnutrition
among infants than other age groups.19
Some studies from different countries
reported a significant relationship between
gender and malnutrition. A study from Iran has
reported higher prevalence of stunting in
Article
Table 3. Results of the logistic regression analysis of variables, which are significantly related to wasting, underweight, stunting, body
mass index and head circumference among 0-5 year old children.
Variable Wasting Underweight Stunting BMI-for-age ≤−2SD Head circumference
P; OR (95%CI) P; OR (95%CI) P; OR (95%CI) P; OR (95%CI) ≤−2SD
P; OR (95%CI)
History of prematurity
Yes * 0.003; 3.18 (1.47-6.88) 0.001; 3.53 (1.62-7.68) 0.002; 3.39 (1.54-7.45) 0.000; 7.11 (2.73-18.54)
No (Ref) - - - - -
Socioeconomical status
Low 0.039;1.01 (0.56-1.81) 0.045; 0.95 (0.56-1.62) 0.035; 1.20 (0.69-2.11) * 0.055; 2.14 (0.98-4.69)
Intermediate * * * * *
High (Ref) - - - - -
Educational level of father
Primary or less 0.016; 22.16 (1.79-274.0) 0.028, 4.90 (1.34-164.92) * * *
Secondary * 0.043; 11.29 (1.07-118.72) * * *
High * * * * *
University (Ref) - - - - -
Employment status of father
Employed (Ref) - - - - -
Unemployed 0.028; 1.78 (1.06-2.98) * 0.008; 1.99 (1.19-3.33) 0.005; 2.11 (1.25-3.56) 0.049, 1.94 (1.00-3.76)
Parental consanguity
None (Ref) - - - - -
Present * 0.032; 1.66 (1.04-2.66) * * *
Regular intake of vitamin D
Yes (Ref) - - - - -
No * * 0.024; 2.40 (1.12-5.14) * *
Interval between pregnancies
<1 years * * * * *
1-2 years * * * 0.017; 2.72 (1.19-6.20) *
>2 years (Ref) - - - - -
Number of pregnancies
1(Ref) - - - - -
2 * * 0.021; 4.97 (1.27-19.37) * *
3 * * * * *
>3 * * * * *
Ref=reference category; *results which were not statistically significant.

[Pediatric Reports 2016; 8:6112] [page 19]
males compared to female children; however,
underweight and wasting have not significant-
ly related with gender.20 But another study
from a different region of Iran, has shown sig-
nificant higher rates of wasting and stunting
in girls, while no statistical difference in
respect of underweight.19 Bhutia et al. men-
tioned that severe underweight was higher for
girls than boys and, as an interesting result,
the median duration of breastfeeding was 2
months longer for males than females in
India.4In contrast, Jiang et al. have reported
that girls had a lower risk of becoming stunted
than boys.18 In our study, there was not a sig-
nificant relationship between malnutrition
and gender.
Multivariate analysis of our results revealed
that there was a statistically significant corre-
lation between regular intake of vitamin D and
stunting. Micronutrient deficiencies (especial-
ly iron, iodine, zinc and vitamin A, C, D and B)
affect nearly 2 billion people worldwide and are
major public health problems in developing
countries.16 Vitamin D deficiency has been
found in association with both skeletal and
nonskletal (cardiovascular disease, certain
cancers, cognitive decline, autoimmunity and
allergy) poor consequences in childhood that
each of them is a contributive factor for malnu-
trition.21 Likely with our results, these findings
indicates the crucial role of vitamin D in opti-
mal growth and development of children.
Our results have shown that the occupation
and educational status of fathers were in a
close relationship with prevalence of malnutri-
tion. Previous studies have reported different
results concerning this association. Kavosi et
al. did not find a significant relationship
between children’s nutritional status and
father’s education level in Iran.20 In additon,
there were no statistically association between
father’s education level or working status and
malnutrition in Malaysia.22 As Ergin et al.,
mentioned before, father education level
becomes more important than mother’s in
developing countries like Turkey, where the
females’ education level is low,11 we suggested
that the fact of traditional male dominance in
family economy and crowded home population
might be a significant contributing factor in
high rates of malnutrition prevalence.
Weight-for-age index cannot distinguish
between current or past energy deficit.
Similarly, height-for-age is an index of cumu-
lative past energy deficit but cannot show cur-
rent energy intake. While, BMI is an index of
current energy deficit because it is based on
current weight and current height of children
but it can not differentiate between adiposity
(fat mass) and muscularity (lean mass).23,24 In
additon it has been proposed that as a index of
current energy deficit, early detection of low
BMI for age can be a marker for future stunt-
ing, while once stunting has occurred, it is vir-
tually irreversible.24 In our study, BMI has suc-
cessfully detected all of the children at the
same time who also determined as mal-
noushired using weight-for-height index.
However Ramachandran et al. have mentioned
that, the median and −2SD values for BMI-for-
age index of Indian children were lower than
WHO-2006 standards in the first month of life
and also, the median of Indian children was
higher from WHO standards by three months,
we thought that BMI-for-age is a useful screen-
ing parameter in children but further investi-
gations are needed for local settings like our
country.24
Prematurity was found as a global risk factor
for malnutrition in our study. However, the
ideal growth pattern of preterm infants
remains undefined and catch-up growth tim-
ing could differ among premature babies,
there are specific growth charts for determin-
ing the growth status of the premature infant
based on the WHO recommendations.25,26 In
addition, recent advances in neonatal care
have resulted in improved survival of very
and/or extremely low birth weight neonates
and it has been reported that nearly 75% of
such infants remained as underweight and
stunted, almost 50% having microcephaly and
wasting at 1 year of corrected age.27
Conclusions
Prevalence of malnutrition among under-
five children in Van city was relatively high in
respect of western regions of Turkey. The risk
factors of malnutrition in childhood are well
described worldwide, but to minimize their
influence on malnutrition are duty of both
health professionals, public authorities, educa-
tional institutions and also civil society organ-
izations.
Limitations
Present study had some limitations. Firstly,
we performed this study in an urban area and
we did not determine whether the subjects
were born in or came from a rural area before
study period. Secondly, as a cause of acute mal-
nutrition, we did not investigate the acute ill-
ness history, especially recent infections such
as diarrheae or pneumonia in wasted children.
We also did not evaluate the maternal nutri-
tional status, which is directly in correlation
with nutritional status of children.
Compliance with ethical standards
All procedures performed in studies involv-
ing human participants were in accordance
with the ethical standards of the institutional
and/or national research committee and with
the 1964 Helsinki declaration and its later
amendments or comparable ethical standards.
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