N UTRITIONAL S TATUS OF C HILDREN

The anthropometric data on height and weight collected in the 2014 GDHS permit the measurement and evaluation of the nutritional status of young children in Ghana. This evaluation allows identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death. Marked differences, especially with regard to height-for-age, weight-for-height, and weight-for-age, are often seen among subgroups of children within the country.

11.1.1 Measurement of Nutritional Status among Young Children

The 2014 GDHS collected data on the nutritional status of children under 5 by measuring their height and weight. Measurements were done in the subsample of households selected for the male survey and biomarker collection, regardless of whether the children’s mothers were interviewed in the survey.

Data were collected to calculate three indices: height-for-age, weight-for-height, and weight-for-age.

Weight measurements were obtained using a SECA 878 digital scale, designed for weighing children and adults. Height measurements were carried out using a Shorr Productions measuring board. Children younger than 24 months were measured lying down on the board (recumbent length), and standing height was measured for older children.

Indicators of the nutritional status of children were calculated using new growth standards published by the World Health Organization (WHO) in 2006. These new growth standards were generated through data collected in the WHO Multicenter Growth Reference Study (WHO 2006). The findings of that study, which sampled 8,440 children in six countries (Brazil, Ghana, India, Norway, Oman, and the United States), describe how children should grow under optimal conditions. The WHO child growth standards can therefore be used to assess children all over the world, regardless of ethnicity, social and economic influences, and feeding practices. The new growth standards replace the previously used NCHS/CDC/WHO reference standards. The three indices are expressed in standard deviation units from the Multicenter Growth Reference Study median.

Each of these indices—height-for-age, weight-for-height, and weight-for-age—provides different information about growth and body composition that can be used to assess nutritional status. The height-for-age index is an indicator of linear growth retardation and cumulative growth deficits. Children whose height-for-age Z-score is below minus two standard deviations (-2 SD) from the median of the reference population are considered short for their age (stunted), or chronically malnourished. Children who are below minus three standard deviations (-3 SD) are considered severely stunted. Stunting reflects failure to receive adequate nutrition over a long period and is also affected by recurrent and chronic illness. Height-for age, thereHeight-fore, represents the long-term effects of malnutrition (specifically, undernutrition) in a population and is not sensitive to recent, short-term changes in dietary intake.

The weight-for-height index measures body mass in relation to body height or length and describes current nutritional status. Children whose Z-scores are below -2 SD from the median of the reference population are considered thin (wasted), or acutely malnourished. Wasting represents the failure to receive adequate nutrition in the period immediately preceding the survey. It may result from inadequate food intake or a recent episode of illness causing loss of weight and the onset of malnutrition. Children whose weight-for-height is below -3 SD are considered severely wasted.

Overweight and obesity are other forms of malnutrition that are becoming concerns for some children in developing countries. Children whose Z-score values are +2 SD above the median for weight-for-height are considered overweight.

Weight-for-age is a composite index of height-for-age and weight-for-height. It takes into account both acute and chronic malnutrition. Children whose weight-for-age is below -2 SD from the median of the reference population are classified as underweight. Children whose weight-for-age is below -3 SD from the median are considered severely underweight.

Nutrition of Children and Women • 155 Z-score means are also calculated as summary statistics representing the nutritional status of children in a population. These mean scores describe the nutritional status of the entire population without the use of a cut-off. A mean Z-score of less than 0 (i.e., a negative value for stunting, wasting, or underweight) suggests that the distribution of an index has shifted downward and, on average, children in the population are less well-nourished than children in the WHO Multicentre Growth Reference Study.

11.1.2 Data Collection

Height and weight measurements were obtained for 3,118 children under age 5 who were present in the 2014 GDHS sample households at the time of the survey. The nutritional status report covers the 97 percent of children for whom complete and credible anthropometric and age data were collected. The analysis of the anthropometric data on height and weight allows the evaluation of the nutritional status of young children and the identification of subgroups of the child population that are at increased risk of faltered growth, disease, impaired mental development, and death.

11.1.3 Levels of Child Malnutrition

Table 11.1 and Figure 11.1 show the percentage of children under 5 classified as malnourished according to the three anthropometric indices of nutritional status (height-for-age, weight-for-height, and weight-for-age). Overall, at the time of the 2014 GDHS, 19 percent of children were stunted, 5 percent were wasted, and 11 percent were underweight.

Height-for-age

Analysis by age group shows that stunting peaks in children age 24-35 months (28 percent) and is lowest (6 percent) in children age 6-8 months (Figure 11.1). Both stunting and severe stunting are slightly higher in male children (20 percent and 5 percent, respectively) than in female children (17 percent and 5 percent, respectively). Children with a preceding birth interval shorter than 24 months are at the highest risk of being stunted (29 percent) when compared with the first-born children and children with a preceding birth interval longer than 24 months. Forty percent of children whose size at birth was reported by mothers to be very small are stunted, which is twice the national average of stunting. Children in rural areas are more likely to be stunted (22 percent) than those in urban areas (15 percent). Regional variations are apparent, with stunting prevalence being the highest in Northern region (33 percent) and the lowest in the Greater Accra region (10 percent). Mother’s educational level generally has an inverse relationship with children’s stunting: the proportion of stunting declines drastically from 26 percent among children of mothers with no education to only 4 percent among children whose mothers have a secondary or higher education. A similar inverse relationship is observed between household wealth and stunting levels.

Children in the poorest households are almost three times as likely to be stunted as children in the wealthiest households (25 percent versus 9 percent).

Weight-for-height

Table 11.1 indicates that wasting is highest in children 9-11 months (11 percent) and lowest in children 36-47 months (1 percent). Female children are more likely to be wasted (5 percent) than male children (4 percent). As is the case with stunting, children who were reportedly very small at birth are most likely to be wasted (8 percent) when compared with other children. By residence, children residing in urban areas are slightly less likely to be wasted than children in rural areas (4 percent versus 6 percent).

Wasting levels in children across regions exist, ranging from a low of 3 percent among children in Volta to 9 percent among children in Upper East. There is no clear correlation between other background characteristics such as mother’s education or wealth and wasting levels.

Table 11.1 Nutritional status of children

Percentage of children under 5 classified as malnourished according to three anthropometric indices of nutritional status: height-for-age, for-height, and weight-for-age, by background characteristics, Ghana 2014

Height-for-age¹ Weight-for-height Weight-for-age

Number Not interviewed and not in

the household⁵ 6.8 26.5 -1.1 0.3 5.1 1.4 -0.2 1.6 14.3 1.2 -0.8 240 Note: Table is based on children who stayed in the household on the night before the interview. Each of the indices is expressed in standard deviation units (SD) from the median of the WHO Child Growth Standards adopted in 2006. The indices in this table are NOT comparable to those based on the previously used NCHS/CDC/WHO reference. Table is based on children with valid dates of birth (month and year) and valid measurement of both height and weight. The total includes four children for whom information on size at birth is missing.

1 Recumbent length is measured for children under age 2, or in the few cases when the age of the child is unknown and the child is less than 87 cm; standing height is measured for all other children.

2 Includes children who are below -3 standard deviations (SD) from the WHO Child Growth standards population median

3 Excludes children whose mothers were not interviewed

4 First-born twins (triplets, etc.) are counted as first births because they do not have a previous birth interval

5 Includes children whose mothers are deceased

6 Excludes children whose mothers were not weighed and measured, children whose mothers were not interviewed, and children whose mothers were pregnant or gave birth within the preceding 2 months. Mother’s nutritional status in terms of BMI (body mass index) is presented in Table 11.10.1.

7 For women who are not interviewed, information is taken from the Household Questionnaire. Excluded are children whose mothers are not listed in the Household Questionnaire.

Nutrition of Children and Women • 157

Weight-for-age

In Ghana, the peak levels of low weight-for-age are found among children 18-23 months (15 percent), followed by those age 24-35 months (14 percent). There are no major differences by gender. The percentage of children who are underweight shows a strong correlation with child’s size at birth as perceived by mothers.

Children born to thin mothers (BMI < 18.5) are more than four times as likely to be underweight (22 percent) as children born to mothers who are overweight/obese (5 percent). Children living in rural areas are more likely to be underweight than those in urban areas (13 percent and 9 percent, respectively).

The proportion of underweight children ranges from 6 percent in the Brong Ahafo region to 20 percent in the Northern region. Children born to mothers with little or no education are substantially more likely to be underweight than children of more educated women.

Figure 11.1 Nutritional status of children by age

11.1.4 Trends in Children’s Nutritional Status

Figure 11.2 displays the trends in the proportion of children under 5 who are stunted, wasted, or underweight between the 2003 and 2014 GDHS surveys. The data show a downward trend and reveal that all three nutritional status indices have improved in the last decade.

The proportion of stunted children has decreased steadily from 35 percent in 2003 to 19 percent in 2014. The proportion of wasted children has decreased from 8 percent in 2003 and 9 percent in 2008, to 5 percent in 2014. The proportion of underweight children has decreased from 18 percent in 2003 to the current level of 11 percent. Overweight among children fluctuated between 4-5 percent between 2003 and 2008, and is currently at 3 percent.

0 5 10 15 20 25 30 35

0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36 38 40 42 44 46 48 50 52 54 56 58 Percent

Age (months)

Stunted Wasted Underweight

Note: Stuntingreflects chronic malnutrition; wasting reflects acute malnutrition; underweightreflects chronic or acute malnutrition or a combination of both. Plotted

values are smoothed by a five-month moving average. GDHS 2014

Figure 11.2 Trends in nutritional status of children under age 5, Ghana 2003-2014