The prevalence of stunting, wasting, overweight and their coexistence are various in different populations and they also have changed with social developing and environmental improving. In this paper, we aimed to analyze the prevalence of stunting, wasting, overweight and their coexistence in some developed regions of China. Data were collected in a population-based cross-sectional survey by a multi-stage cluster sampling method in nine cities located in the northern, central, and southern region of China in 2016. Children under seven years (n = 110,491) were measured. WHO growth standards were used to assess the growth status. Stunting, underweight, wasting, overweight and obesity were considered as the primary forms of malnutrition (includes undernutrition and overnutrition) for infant or young children at population-levels. The prevalence of stunting, underweight, wasting, and overweight or obesity were respectively 0.7%, 0.6%, 1.2%, and 7.6%. Most of these children (95.4%) suffered from one form of malnutrition, and only 0.2% of them concurrently stunted and wasted, 0.4% concurrently stunted and overweight, 1.7% concurrently stunted and underweight, 2.3% concurrently underweight and wasted. Among stunted children, 91.2% were appropriate body proportion, and only 2.3% were wasted, 6.5% were overweight or obesity. Among overweight or obese children, only 0.6% were stunted, whereas, 15.8% were high stature and 83.6% were the appropriate ranges of stature. Sex, age, urban/suburban, and region were associated with these primary forms of malnutrition in the multivariate logistic analysis. In conclusion, we found that the coexistence of stunting and overweight was not common at both population-level and individual-level. The situation for undernutrition had significantly improved, and overweight may be the leading public health issue for children under seven years in the nine cities of China.

Citation: Zhang Y-Q, Li H, Wu H-H, Zong X-N (2021) Stunting, wasting, overweight and their coexistence among children under 7 years in the context of the social rapidly developing: Findings from a population-based survey in nine cities of China in 2016. PLoS ONE 16(1): e0245455. https://doi.org/10.1371/journal.pone.0245455

Editor: Srinivas Goli, University of Western Australia, AUSTRALIA

Received: January 13, 2020; Accepted: January 1, 2021; Published: January 14, 2021

Copyright: © 2021 Zhang et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The authors are restricted from sharing the raw data because the data used in this study are owned by the National Health Commission of the People’s Republic of China and the ethical approval and participant consent for this survey also does not allow the public sharing of raw data. However, interested qualified researchers may send data requests to the Ethics Committee of the Capital Institute of Pediatrics ([email protected]).

Funding: The survey was supported by National Health Commission of the People’s Republic of China. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Stunting, underweight, wasting, overweight and obesity are considered as the primary forms of malnutrition in early childhood, and they present high epidemic trends and continue to pose significant public health concerns [1]. Malnutrition of young children has adverse health and development consequences for the affected during childhood, posed long-term health risks during adulthood [2, 3], and brings serious diseases and economic burden to families and society. Especially, the research on the developmental origins of health and disease has shown that the early life malnutrition is risk factor for the adverse consequences throughout the life course [3, 4]. Therefore, infant and young children and preschool children malnutrition remains a fundamental challenge in improving human development, reduction of stunting prevalence and no increase in childhood overweight were considered as the most crucial goal of the Global nutrition targets for 2025 [5]. In addition, eradicating all forms of malnutrition: wasting, stunting, underweight, vitamin and mineral deficiency, overweight or obesity and diet-related NCDs, is an essential target of the United Nations Decade of Action on Nutrition 2016–2025 and the Agenda for Sustainable Development by 2030.

The 2018 Global Nutrition Report has illustrated that the burden of malnutrition was diverse in different regions worldwide: overweight and obesity are the primary forms of malnutrition in some developed countries; wasting, underweight or stunting are most prevalent in low and lower-middle-income countries [6]; while many of those rapidly developing countries were said to suffer double burden of malnutrition at population level, which is characterized by the relative high prevalence of stunting along with relative high prevalence of overweight and obesity in populations [7]. Besides, the latest available data also indicate that some children suffer from more than one form of malnutrition at the individual-level; for example, the prevalence of coexistence of stunting and overweight in European, African and American populations was respectively 2.7%, 2.3% and 0.8%, and the prevalence of coexistence of stunting and wasting in Asian, African and European population was 5.0%, 2.9% and 0.2% [6]. Thus, we can find that there are various patterns of malnutrition burden at the population-level as well as at the individual-level within countries or regions worldwide, and they are changing with socially developing and environmentally improving in populations. Obtaining the data on the prevalence of various forms of malnutrition will be helpful to recognize the real situation of malnutrition in a population, which supports the decision-makers in designing suitable actions for combating undernutrition or overnutrition due to their different risk factors. But geospatial data on who is affected by what form of malnutrition is not enough. Therefore, it is critical to collect more data about the wasting, stunting, underweight, overweight and their coexistence in a given place and a given time in order to know about progress to prevention for children malnutrition, make effective policies suitable for a specific region and time, and control their global epidemic.

In China, there are rapid social-economic developing and environmental improvement during the past decades [8], and children have achieved remarkable improvements in physical growth [9, 10]. Some reports have shown that the patterns of malnutrition have been changing [11–15]. Furthermore, an analysis in impoverished areas of China illustrates that there were 57.6% of overweight children coexist stunting, which suggests that the dual burden of malnutrition has become the new challenge in impoverished areas of China [12]. However, what about their situation among young children in affluent areas of China, where the feeding pattern of infants had been improved and similar to those in developed countries [16]? These data are still lacking. Therefore, a large scale cross-sectional survey based on population was conducted in nine cities of China in 2016 to fully understand the prevalence of wasting, underweight, stunting, overweight and their coexistence in developed regions and supply more data for knowing about malnutrition in different socially developing backgrounds.

During June and December 2016, a cross-sectional survey was conducted in nine cities of China: Beijing, Harbin, Xi’an, Shanghai, Nanjing, Wuhan, Guangzhou, Fuzhou, and Kunming. Beijing, Harbin, Xi’an are considered as northern region, Shanghai, Nanjing, Wuhan as central region, and Guangzhou, Fuzhou, Kunming as southern region according to their latitude (Fig 1). Besides, Beijing and Shanghai are municipalities, and the rest are the provincial capital cities. Each city includes urban areas and suburban areas.

https://doi.org/10.1371/journal.pone.0245455.g001

All children aged older than one month and younger than seven years were included and the exclusion criteria were: (1) Those with severe physical disabilities whose weight or height could not be measured, for example, limb deficiency, paralysis and so on; (2) Those who refused to participate in the survey.

Multi-stage stratified cluster sampling method was used according to urban/suburban areas and administrative districts in each city. There were 1 to 3 administrative districts selected in urban or suburban areas in each city, and all the sub-districts in the selected administrative districts, which were considered as the cluster sample unit, were coded and selected using systematic random sampling methods. Data was collected in these selected sub-districts. The sample size of children under seven years of the selected sub-districts were not less than 5,000 (calculated by the formula , P = 3%, δ = 0.5%, which were based on the related reference [14] and 10% refusing to visit) in urban or suburban areas in each city.

Children were barefoot and wore the lightest vest, shorts or underwear, and then these indicators of physical growth were measured. The length of children under 3 years were measured using Infantometer (maximum range of 110 cm, and accurate to 0.1 cm) and height of children aged 3 years or older were measured using Height-Sitheight Stadiometer (maximum range of 150 cm, and accurate to 0.1 cm). The length or height was recorded by the reading to the nearest to 0.1cm. The weight of all children was measured by an Electronic scale (maximum range of 250 kg and accurate to 50 g). Investigators of this research took these key growth measurements using unified standardization methods [9]. BMI was calculated as weight/height2 (kg/m2). Other information on the characteristics of participants, including urban/suburban, dates of birth and sex, were collected by the registration system for children health care and the exact age of children was calculated by “dates of visit minus dates of birth”.

The children’s height/length for age Z-scores (HAZ), weight for age Z-scores (WAZ) and BMI for age Z-scores (BMIZ) were calculated based upon the WHO Child Growth Standards (2006) [17] for under 60 months children and the WHO child growth reference (2007) [18] for children aged 60-83months. Because we measured the length for children aged 24–35 months, they had been transformed into height by reducing 0.7cm in length [17] then their HAZ was calculated, and BMI for 24-35months children was calculated after changing the length to height.

Stunting was defined as HAZ +3 were categorized as being at risk of overweight, overweight and obesity, respectively, and children aged 60-83months with BMIZ >+1, >+2 were categorized as being overweight and obesity. Coexistence of stunting and overweight referred to the children under 60months with the combination of HAZ +2 and children aged 60-83months with the combination of HAZ+1. The coexistence of stunted and wasted referred to the children with the combination of HAZ