Early childhood linear growth faltering in low-income and middle-income countries as a whole-population condition: analysis of 179 Demographic and Health.

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Early childhood linear growth faltering in low-income and middle-income countries as a whole-population condition: analysis of 179 Demographic and Health Surveys from 64 countries (1993–2015) Daniel E Roth, PhD, Aditi Krishna, ScD, Michael Leung, MSc, Joy Shi, MSc, Diego G Bassani, PhD, Prof Aluisio J D Barros, PhD The Lancet Global Health Volume 5, Issue 12, Pages e1249-e1257 (December 2017) DOI: 10.1016/S2214-109X(17)30418-7 Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 1 Trends in cross-sectional HAZ distribution parameters for successive 3-month age bands Figure shows data for 2148 survey-age units. (A) Mean, fifth percentile, and 95th percentile. (B) Standard deviation. HAZ=height-for-age Z score. The Lancet Global Health 2017 5, e1249-e1257DOI: (10.1016/S2214-109X(17)30418-7) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 2 Predicted linear fit lines representing the associations of standard deviation (A) or fifth and 95th percentiles (B) of HAZ distribution with mean HAZ Figure based on multilevel regression models for 2148 survey-age units. Trend lines for individual surveys are best linear unbiased predictions based on survey-level and country-level random intercepts and random slopes at the survey level. In panel A, the two surveys with predicted slopes that most differed from the grand mean slope was Uzbekistan 1996 (n=1086), for which the predicted slope was 0·041, and Guyana 2009 (n=1185), for which the predicted slope was 0·046. No other surveys had predicted slopes for the association of standard deviation with mean HAZ that indicated that standard deviation increased as mean HAZ declined. HAZ=height-for-age Z score. The Lancet Global Health 2017 5, e1249-e1257DOI: (10.1016/S2214-109X(17)30418-7) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions

Figure 3 Simulations to demonstrate the theoretical effect of a set of growth-limiting exposures on standard deviation, fifth percentile, and 95th percentile of HAZ distribution for a simulated population of 10 000 children with an initial mean HAZ=0 and SD=1 (A) 25% of the population exposed; average standard deviation when mean HAZ=–2 was 3·63. (B) 50% of the population exposed; average standard deviation when mean HAZ=–2 was 2·25. (C) 75% of the population exposed; average standard deviation when mean HAZ=–2 was 1·55. (D) 100% of the population exposed; average standard deviation when mean HAZ=–2 was 1·02. Monte Carlo simulation (1000 repetitions) was used to simulate a faltering process in which the mean HAZ declined from 0 to −2 via cumulative 0·1 decrements in the fixed group of exposed children. Lines represent smoothed trends of the average standard deviation, 5th percentile, and 95th percentile. HAZ=height-for-age mean Z score. The Lancet Global Health 2017 5, e1249-e1257DOI: (10.1016/S2214-109X(17)30418-7) Copyright © 2017 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license Terms and Conditions