Influences on catch-up growth using relative versus absolute metrics: evidence from the MAL-ED cohort study

Stephanie A Richard, Benjamin J J McCormick, Laura E Murray-Kolb, Pascal Bessong, Sanjaya K Shrestha, Estomih Mduma, Tahmeed Ahmed, Gagandeep Kang, Gwenyth O Lee, Jessica C Seidman, Erling Svensen, Margaret N Kosek, Laura E Caulfield* (Corresponding Author), MAL-ED Network Investigators

*Corresponding author for this work

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BACKGROUND: Poor growth in early childhood has been considered irreversible after 2-3 years of age and has been associated with morbidity and mortality over the short-term and with poor economic and cognitive outcomes over the long-term. The MAL-ED cohort study was performed in eight low-income settings with the goal of evaluating relationships between the child's environment and experience (dietary, illness, and pathogen exposure, among others) and their growth and development. The goal of this analysis is to determine whether there are differences in the factors associated with growth from 24 to 60 months using two different metrics.

METHODS: Across six MAL-ED sites, 942 children had anthropometry data at 24 and 60 months, as well as information about socioeconomic status, maternal height, gut permeability (lactulose-mannitol z-score (LMZ)), dietary intake from 9 to 24 months, and micronutrient status. Anthropometric changes were in height- or weight-for-age z-score (HAZ, WAZ), their absolute difference from the growth standard median (HAD (cm), WAD (kg)), as well as recovery from stunting/underweight. Outcomes were modeled using multivariate regression.

RESULTS: At 24 months, almost half of the cohort was stunted (45%) and 21% were underweight. Among those who were stunted at 24 months (n = 426), 185 (43%) were no longer stunted at 60 months. Most children increased their HAZ from 24 to 60 months (81%), whereas fewer (33%) had positive changes in their HAD. Linear regression models indicate that girls improved less than boys from 24 to 60 months (HAZ: -0.21 (95% CI -0.27, -0.15); HAD: -0.75 (-1.07, -0.43)). Greater intestinal permeability (higher LMZ) at 0-24 months was associated with lower relative and absolute changes from 24 to 60 months (HAZ: -0.10 (-0.16, -0.04); HAD: -0.47 (-0.73, -0.21)). Maternal height (per 10 cm) was positively associated with changes (HAZ: 0.09 (0.03, 0.15); HAD: 0.45 (0.15, 0.75)). Similar relationships were identified for changes in WAZ and WAD.

CONCLUSIONS: The study children demonstrated improved growth from 24 to 60 months of age, but only a subset had positive changes in HAD and WAD. The same environmental factors were associated with growth from 24 to 60 months regardless of metric used (change in HAZ or HAD, or WAZ and WAD).

Original languageEnglish
Article number1246
Number of pages12
JournalBMC Public Health
Issue number1
Publication statusPublished - 29 Jun 2021

Bibliographical note

The Etiology, Risk Factors and Interactions of Enteric Infections and Malnutrition and the Consequences for Child Health and Development Project (MAL-ED) was a collaborative project led by the Foundation for the National Institutes of Health and the National Institutes of Health, Fogarty International Center. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. National Institutes of Health or Department of Health and Human Services.
The MAL-ED study was supported by the Bill & Melinda Gates Foundation, through grants to the Foundation for the National Institutes of Health, and with additional support from the National Institutes of Health, Fogarty Inter- national Center. The funder had no direct role in the writing of the manu- script or in the study design, data collection, analysis or interpretation of study results. We are grateful to the children and caregivers who participated in the study for their invaluable contributions.

Data Availability Statement

The dataset supporting the analyses presented here can be obtained by requesting the data from the corresponding author. We are not posting this specific file in a repository because data from the MAL-ED study are publicly available (upon request) through the ClinEpiDB platform (https://clinepidb. org). The link to the specific record to explore study data and request a download of the data is c41b87221


  • Benchmarking
  • Body Height
  • Body Weight
  • Child
  • Child, Preschool
  • Cohort Studies
  • Female
  • Growth Disorders/epidemiology
  • Humans
  • Infant
  • Male


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