Infant and young child feeding practices in urban
Philippines and their associations with stunting,
anemia, and deficiencies of iron and vitamin A
Fabian Rohner, Bradley A. Woodruff, Grant J. Aaron, Elizabeth A. Yakes,
May Antonnette O. Lebanan, Pura Rayco-Solon, and Ofelia P. Saniel
Abstract
Background. The prevalence of stunting, underweight,
and micronutrient deficiencies are persistently high in
young children in the Philippines, and among other fac-
tors, suboptimal infant and young child feeding behavior
may contribute to these forms of malnutrition.
Objective. To improve the understanding of contribu-
tors associated with the nutritional status of children 6 to
23 months of age living in urban areas of the Philippines.
Methods. A cross-sectional survey was conducted
covering five urban centers in the Philippines. Data on
infant and young child feeding and nutritional status
(including wasting, stunting, underweight, anemia, iron
deficiency, and vitamin A deficiency) were collected for
1,784 children.
Results. Among children from urban and predomi-
nantly poor and very poor households, 26% were stunted,
18% were underweight, and 5% were wasted. Forty-two
percent were anemic, 28% were iron deficient, and 3%
were vitamin A deficient. About half of the children were
breastfed within an hour after birth, were breastfed at the
time of the survey, and had been continuously breastfed
up to 1 year of age. Of the factors investigated, low socio-
economic status, use of cheaper cooking fuel, and nonuse
of multivitamins were all independently associated with
stunting. The prevalence of anemia, iron deficiency, and
vitamin A deficiency were independently associated
Fabian Rohner is affiliated with GroundWork LLC,
Crans-près-Céligny, Switzerland, and the Global Alliance for
Improved Nutrition (GAIN), Geneva; Switzerland. Bradley
A. Woodruff is affiliated with GroundWork LLC, Crans-près-
Céligny, Switzerland; Grant J. Aaron is affiliated with GAIN,
Geneva; Elizabeth A. Yakes is affiliated with the University of
New Mexico, Albuquerque, New Mexico, USA; May Antonette
O. Lebanan and Ofelia P. Saniel are affiliated with the Univer-
sity of the Philippines, College of Public Health, Manila; Pura
Raycon-Solon is affiliated with UNICEF, Manila.
Please direct queries to the corresponding author: Ofelia P.
Saniel, Department of Epidemiology, College of Public Health
University of the Philippines Manila, 625 Pedro Gil Street,
Ermita, Manila, Philippines 1000; e-mail: opsaniel@gmail.com.
Food and Nutrition Bulletin, vol. 34, no. 2 (supplement) © 2013, The United Nations University.
with the same factors and poorer sanitation facilities,
lower maternal education, current unemployment, and
inflammation.
Conclusions. These factors merit attention in future
programming, and interventions may include promotion
of the timely introduction of appropriate fortified com-
plementary foods, the use of affordable multiple micro-
nutrient preparations, and measures to reduce infections.
Key words: Micronutrient deficiencies, Philippines,
stunting, young child feeding practices
Introduction
Elimination of extreme poverty and hunger and reduc-
tion of child mortality are among the Millennium
Development Goals (MDGs) set by the United Nations
to be achieved by 2015. With only 2 years left, the
Philippines and many other countries are trying to
further reduce mortality rates and the high prevalence
of undernutrition among infants and young children.
Yet, although progress was made in reducing under-
five and infant mortality rates over the past decade
[1] in the Philippines, the prevalence of stunting and
underweight among children under 5 years of age has
remained constant, with about a quarter of this age
group being affected in 2008 [2]. Stunting, under-
weight, and wasting have repeatedly been identified as
contributors to mortality, and therefore, achievement
of MDG 5 will also depend on reductions in stunting,
underweight, and wasting [3].
The prevalence of anemia among children under 2
years of age has remained persistently high in the face
of marked reductions in anemia among older children
and pregnant and lactating women in the Philippines.
Anemia data from the 2008 National Nutrition Survey
[2] showed that about 20% of the total population was
anemic. However, among children 6 to 11 and 12 to
23 months of age, the prevalence of anemia was 56%
and 41%, respectively, which represents only a very
S17
S18
moderate improvement since 2003 [2].
Infants and young children also have a markedly
higher prevalence of vitamin A deficiency than the gen-
eral population. Vitamin A data from the 2008 National
Nutrition Survey demonstrate that the national preva-
lence of vitamin A deficiency was 6%, whereas in
children aged 6 to 59 months the prevalence was 15%;
however, this prevalence is considerably lower than
that in the period before 2003, when the prevalence
of vitamin A deficiency in young children fluctuated
around 40%. The decrease in vitamin A deficiency may
be due to the enactment of mandatory fortification of
edible oil [2].
Suboptimal feeding patterns, low household socioec-
onomic status and parental education levels, poor child
health status, and inadequate sanitation have all been
previously linked to child mortality and malnutrition
in the Philippines [1, 4]. In order to ameliorate this, a
multiple stakeholder program was instituted to build
on government initiatives to improve rates of exclusive
breastfeeding during the first 6 months of life and age-
appropriate complementary feeding practices among
children 6 to 23 months old. The premise behind
this is that improved infant and young child feeding
(IYCF) should lead to improved child nutrition and
micronutrient status, and consequently to reductions
in child mortality.
The data presented in this study were collected as
part of a larger study examining IYCF patterns and
their influence on malnutrition, with a focus on the
assessment of micronutrient status. The goal of this
study is to improve the understanding of how deter-
minants such as demographic variables, household
characteristics, and infant and young child feeding
practices relate to anthropometric and micronutrient
status among children aged 6 to 23 months living in
the Philippines.
Design and methods
Survey design
This survey collected baseline data in five urban areas
(Manila, Cebu, Zamboanga, Naga, and Iloilo cities)
where strengthened efforts to improve IYCF practices
were to be implemented. The survey participants in
each urban area were selected by stratified two-stage
cluster sampling. Within each urban area, the baran-
gays (the smallest administrative divisions in the Philip-
pines) served as the basis for forming primary sampling
units (PSUs). Most barangays were by themselves one
PSU; however, small barangays with fewer than 500
households were merged with adjacent ones to form a
single PSU. PSUs were then selected systematically with
probability proportional to the number of households
F. Rohner et al.
based on 2007 census data [5]. Some large PSUs were
selected more than once due to their size. In Manila
City, 29 PSUs were selected, in Cebu City 27, in Naga
City 10, in Iloilo City 27, and in Zamboanga City 33.
The secondary sampling units were children under 2
years of age, randomly selected from updated census
lists for the selected barangays. For blood sampling,
only children aged 6 to 23 months were included, and
in Zamboanga City, a random subsample was selected
for collection of biologic specimens due to the large
number of children in the PSUs.
Sample size
The calculation of the minimum sample size was based
on the national estimates of prevalence of anemia of
55% and 41% among children 6 to 11 and 12 to 23
months of age, respectively [2]. Since these data will
be used as the baseline for several IYCF interventions,
a reduction of anemia prevalence by one-third in each
age group category per site within 2 years was set as
the target; a separate sample size was calculated for
anthropometric outcomes as well (not presented here).
The computations were based on an alpha error of 5%
(one-tailed), a power of 80%, and a design effect of 1.5.
After adjustment for a nonresponse rate of 20%, 170
children 6 to 11 months of age and 278 children 12 to
23 months of age were calculated to be required for
each site, or a total of 448 children 6 to 23 months of
age. Because Naga and Iloilo were treated as one stra-
tum, this sample size was multiplied by four for a total
desired sample size of 1,792 in all four strata.
Ethical review and consent
The Ethics Review Committee of the College of Public
Health, University of the Philippines Manila, approved
the survey protocol (permit number 2010-003). Inclu-
sion in the survey was dependent on the legal care-
taker of the child giving written informed consent
for participation. To compensate for time lost due
to study participation and travel to the phlebotomy
sites, caretakers of participating children were given a
small financial and food contribution. Severely anemic
children were referred to local health centers for appro-
priate diagnosis and treatment; moderately or mildly
anemic children were provided with 30 micronutrient
powder sachets.
Data collection
After the children were selected and consent was
obtained, all eligible subjects were registered according
to household, sex, age, date, and identification number.
The caregivers of the participants answered questions
on demographic factors, health (recent morbidity and
Infant and young child feeding practices in urban Philippines
treatment), socioeconomic status (household income,
housing quality, access to water, electricity, and trans-
port), and child feeding practices and behaviors. In
addition, anthropometric data and biochemical sam-
ples were collected.
Infant and young child feeding (IYCF)
World Health Organization (WHO)-recommended
infant and young child feeding (IYCF) indicators were
used to assess child feeding practices [6]. These indi-
cators cover a range of practices, and provide specific
criteria for assessing the adequacy of those practices at
the population level, including age-appropriate breast-
feeding practices (timing, duration, and exclusivity),
and timely and adequate introduction of high-quality
complementary foods. Several of the eight core IYCF
indicators as well as optional indicators were calculated
based on these WHO guidelines:
» Initiation of breastfeeding within 1 hour after birth
indicates whether or not the newborn was breastfed
within 1 hour of delivery.
» Currently breastfeeding was measured by asking
the mother or caretaker if the child had consumed
breastmilk (by suckling, cup, or bottle feeding)
during the day and night prior to the interview.
» Continued breastfeeding at 1 year applies this same
definition of current breastfeeding to the subgroup
of children 12 to 14.9 months of age.
» Introduction of complementary foods was measured
by asking respondents how many times during the
prior day and night a child 6 to 8.9 months of age had
consumed solid, semisolid, or soft foods.
» Minimum dietary diversity is met if the child had
consumed foods from at least four major food
groups, which included grains and roots, legumes
and nuts, dairy products, meat, eggs, vitamin A–rich
fruits and vegetables, and other fruits and vegetables,
during the prior day and night.
» The definition of minimum meal frequency varies
by age and breastfeeding status; for breastfed chil-
dren, the frequency of eating solid, semisolid, and
soft foods is counted, and for such children 6 to 8.9
months of age, the minimum frequency is two times
in a 24-hour period. For breastfed children 9 to 23
months of age, the minimum frequency is three
times. For nonbreastfed children, the frequency
of milk feeds plus eating solid, semisolid, and soft
foods is counted, and the minimum frequency for
all such children 9 to 23 months of age is four times
in a 24-hour period.
» The minimum acceptable diet meets standards for
both minimum dietary diversity and minimum
meal frequency. For breastfed children, both stand-
ards must be met for their diet to be considered
minimally acceptable. For nonbreastfed children, the
minimum meal frequency used to define minimum
dietary acceptability no longer includes milk feeds.
S19
Such children must have at least two milk feeds
(nonbreastfed) per day along with minimum dietary
diversity and minimum meal frequency of foods
other than milk. Animal-source foods include meat,
milk, and eggs.
It must be noted that the WHO indicator for con-
sumption of iron-rich or iron-fortified foods was not
assessed in this study.
Water and sanitation quality
Several household-related characteristics were clus-
tered together to create three composite indicators of
household water and sanitation quality [1]. “Improved
drinking water source” is defined as piped water or
water from a borehole, protected or semiprotected dug
well, or protected spring or rainwater collection. “Safe
drinking water” has been treated by methods to make
it safer to drink: boiling, bleaching or chlorine treat-
ment, water filter, solar disinfection, improvised filter,
or letting water stand and settle. “Adequate sanitation
facilities” refers to a toilet that flushes or empties into
a piped sewer or septic tank, a closed pit latrine, an
improved pit latrine, or a pit latrine with slab.
Anthropometry
Anthropometric measurements were taken at the
household by experienced and trained anthropo-
metrists using standard techniques [7] and equipment
(weighing scale, Seca 334; length measuring board,
Seca 417, Hamburg, Germany). The length-for-age
(LAZ), weight-for-age (WAZ), and weight-for-length
(WLZ) z-scores for each child were determined using
the WHO 2006 Child Growth Standards [8]. A child
with LAZ < –2.0 is classified as stunted, one with WAZ
< –2.0 as underweight, and one with WLZ < –2.0 as
wasted. Severe stunting, wasting, and underweight are
defined as z-scores < –3.0 for LAZ, WLZ, and WAZ,
respectively.
Blood sampling and analysis
The mothers or caregivers were asked to bring their
children to a designated health center for blood collec-
tion. Trained phlebotomists collected capillary blood
at designated phlebotomy sites by pricking the heel of
children 6 to 11 months of age and the index or middle
finger of children 12 to 23 months of age. For hemo-
globin, one drop of capillary blood was collected and
measured with the Hemocue device (Hb 201+, Äng-
elholm, Sweden). An additional 300 µL of blood was
collected into a lithium-heparin-coated microtainer
(Microvette CB300, Sarstedt, Switzerland), always
maintaining aseptic precautions to protect the infant
from any potential infection due to the prick. Whole
blood was stored on ice for later blood processing in
the field, where whole blood was centrifuged, and
2 ×100 µL of the supernatant plasma was aliquoted for
S20
later analysis and as a backup. Once aliquoted, plasma
samples were stored at –20°C until further shipment
on dry ice for analysis.
Plasma samples for retinol-binding protein (RBP),
plasma ferritin (PF), C-reactive protein (CRP), and
alpha1-acid-glucoprotein (AGP) were analyzed in one
run from < 100 μL plasma using an in-house sandwich
ELISA (VitA-Iron-Laboratories, Willstaett, Germany)
[9]. The laboratory is a participant in the US Centers
for Disease Control and Prevention (CDC) VITAL-
EQA interlaboratory comparison rounds and has a
rigorous internal quality control system.
In children 6 to 23 months of age, anemia was
defined as a hemoglobin concentration < 110 g/L;
mild anemia was defined as hemoglobin concentration
of 100–109 g/L), moderate anemia as a hemoglobin
concentration of 70 to 99 g/L, and severe anemia as
a hemoglobin concentration < 70 g/L. The following
anemia prevalence cutoffs were used to indicate popu-
lation levels of severity: ≥ 40% indicates a severe public
health problem, 20% to 39.9% a moderate public health
problem, 5% to 19.9% a mild public health problem,
and < 4.9% is considered normal [10].
The acute phase proteins CRP and AGP were used
to classify inflammation into four categories: normal
or no inflammation, defined as no elevated acute
phase proteins; incubation period, defined as a CRP
concentration > 5 mg/L; early convalescence, defined
as a CRP concentration > 5 mg/L and an AGP con-
centration > 1 g/L; and late convalescence, defined as
an AGP concentration > 1 g/L. These four stages of
inflammation were then used to adjust ferritin [11]
and RBP (assumed equivalent to retinol) according
to adjustment factors proposed in the literature [12].
Iron deficiency was defined as a ferritin concentra-
tion < 12 µg/L, after adjustment for the effect of sub-
clinical inflammation using both CRP and AGP [11].
Iron-deficiency anemia was defined as the presence of
both anemia and iron deficiency. Similarly, for vitamin
A deficiency, the threshold for RBP was 0.7 µmol/L
after adjustment for inflammation using both CRP
and AGP [12].
Socioeconomic classification
To calculate socioeconomic status, an approach devel-
oped within the Philippines was used [13] whereby
households are grouped into six classes: AB (upper
class), C1 (upper middle class), broad C (broad middle
class), C2 (lower middle class), D (lower class), and E
(extremely low class). A composite score derived by
summing individual scores for characteristics of the
neighborhood, home durability, outdoor and indoor
home quality, household assets, and monthly house-
hold income and electricity bill was calculated to clas-
sify households.
F. Rohner et al.
Data management and analysis
Data entry for the quantitative survey data was com-
pleted using EpiInfo software, version 6. SPSS software,
version 20, was used for data analysis. Design-based
analysis, appropriate for the complex sampling design,
was employed where sampling weights were used in
the estimation of various indicators. For weightings,
absolute population figures for each of the five survey
sites were used to assign a statistical weight for each
household, mother, and child. For continuous data,
means with associated 95% confidence intervals and
medians were computed. For dichotomous data,
frequencies and proportions were generated with
their 95% confidence intervals. Associations between
variables were measured by creating tables correlating a
potential risk factor with one of the nutrition outcomes;
continuous variables were categorized as necessary.
The statistical significance of differences in propor-
tions among subgroups was determined using adjusted
chi-squares. These analyses did not take into account
potential confounding or effect modification. In order
to take into account these effects, multiple logistic
regression models were constructed separately for each
outcome, which included all potential contributory or
confounding variables for which the p value was less
than .20 in bivariate analysis. Second-order interac-
tion terms were also entered for each of the factors.
Backward elimination was then carried out to remove
those interaction terms and variables not significantly
contributing to the model.
Results
Demographic information
A total of 1,777 households were surveyed, and all eli-
gible children in the household were enrolled, resulting
in interview data from 1,784 children 6 to 23 months of
age and 1,711 mothers. For 66 children, the data were
provided by someone other than the child’s mother.
For biological specimen data, the sample size varied
slightly, depending on the indicator.
The characteristics of the participating households
are described in table 1. The vast majority of the
participating households were from the low and very
low socioeconomic classes, with a monthly income
of approximately 14,433 PHP (US$340). Households
are generally large (6.5 members on average), with
all family members sleeping in one room. Of the
households interviewed, almost half used water from
an improved water source, and only few households
(about 7%) with unimproved water sources treated
water to render it safer to drink, resulting in about half
of households consuming “safe” drinking water. Most
households had adequate sanitation facilities.
Infant and young child feeding practices in urban Philippines S21

TABLE 1. Characteristics of households in which selected children lived

No. of Weighted %
Characteristic households or mean 95% CI
No. of household members (mean) 1,777 6.5 6.2, 6.7
Monthly household income (Philippine 1,777 14,433 11,005, 17,862
pesos [PHP]) (mean)
Household income score (%)
1 (≤ 20,000 PHP) 1,582 84.2% 80.9%, 87.1%
2 (20,001–40,000 PHP) 145 11.6% 9.4%, 14.3%
3 (40,001–60,000 PHP) 42 3.3% 2.3%, 4.8%
4 (> 60,000 PHP) 8 0.8% 0.3%, 2.4%
Socioeconomic classification (%)a
C1 3 0.1% 0.0%, 0.5%
Broad C 25 1.0% 0.5%, 1.7%
C2 262 14.2% 11.4%, 17.5%
D 1,151 67.4% 61.7%, 72.6%
E 326 17.4% 12.1%, 24.4%
Cooking fuel (%)
Electricity or natural gas 529 52.1% 46.7%, 57.4%
Kerosene, coal, wood, etc. 1,248 47.9% 42.6%, 53.3%
No. of persons per sleeping room (mean) 1,773 4.6 4.4, 4.8
Improved source of drinking water (%) b
No 736 55.3% 50.8%, 59.8%
Yes 1,033 44.7% 40.2%, 49.2%
Safe drinking water (%) c
No 594 48.2% 43.7%, 52.7%
Yes 1,182 51.8% 47.3%, 56.3%
Adequate sanitation facilities (%) b
No 233 12.4% 8.3%, 18.1%
Yes 1,543 87.6% 81.9%, 91.7%
a. Socioeconomic classification categories collapsed into three groups for subsequent analyses: groups C1, broad
C, and C2 combined into group C.
b. See text for definitions of “improved” and “adequate.”
c. Either water was obtained from a safe source or adequate water treatment was done in the home.

Table 2 provides an overview of the characteristics of
the responding mothers. The mean age of the mothers
was 27.6 years. More than half of responding mothers
had partially or totally completed high school, with an
additional third having attended a university. Despite
the high level of education, 68% of the interviewed
mothers reported being “unemployed.”
Child characteristics
The mean age of the selected children was 15 months,
and the sex ratio was close to 1:1 (table 3). More than
90% of children were born by vaginal delivery, and
23.9% had three or more siblings.
About a third of the children in the study were
reported to have suffered from a fever in the 2 weeks
preceding the interview (self-report from caregiver
interview). A smaller proportion was reported to have
suffered from cough and fast breathing or diarrhea in
the 2 weeks prior to the survey (table 3).
Table 3 presents the detailed results for breastfeeding
and complementary feeding patterns. In brief, early
initiation of breastfeeding and current breastfeeding
were reported for about half of children 6 to 23 months
of age. About half of children 12 to 14 months of age
were still being breastfed. Over 90% of children 6 to 8
months of age had been introduced to complementary
foods. Among children 6 to 23 months of age, the vast
majority met the criterion for adequacy of meal fre-
quency; however, only slightly more than half met the
criteria for minimum dietary diversity and diet accept-
ability. Interestingly, almost three-quarters of mothers
reported giving multivitamins to their children. Among
children 12 months of age or older, about two-thirds
had received a vitamin A supplement in the 6 months
prior to the survey.
Analysis of the relationship between socioeconomic
status and young child feeding behaviors showed that
S22 F. Rohner et al.

TABLE 2. Characteristics of mothers of selected children

No. of Weighted %
Characteristic women or mean 95% CI
Age (yr) (mean) 1,711 27.6 17.2, 28.1
Age group (yr) (%)
< 19 115 8.8% 7.1%, 10.8%
20–29 913 56.3% 52.9%, 59.6%
30–39 587 30.1% 26.5%, 33.9%
≥ 40 96 4.9% 3.7%, 6.5%
Marital status (%)
Never married 109 9.2% 7.3%, 11.5%
Married 885 42.3% 38.4%, 46.2%
Living together 670 45.7% 42.3%, 49.2%
Separated or divorced 42 2.4% 1.4%, 4.0%
Widowed 5 0.5% 0.2%, 1.4%
Educational level (%)
None or preschool only 8 0.4% 0.2%, 1.1%
Elementary schoola 207 10.0% 7.4%, 13.3%
High school or postsecondarya 980 59.1% 55.5%, 62.5%
University or postgraduate 515 30.6% 26.8%, 34.6%
Occupation (%)
Unemployed 1,248 68.4% 64.5%, 72.1%
Professional, clerical, or skilled manual 106 7.9% 5.9%, 10.6%
Sales or service 218 14.9% 12.7%, 17.4%
Unskilled, domestic, or agriculture 134 8.7% 6.8%, 11.1%
Partner’s occupation (%)
Unemployed 148 13.4% 10.7%, 16.7%
Professional, clerical, or skilled manual 660 41.7% 37.5%, 46.0%
Sales or service 195 12.8% 10.7%, 15.2%
Unskilled, domestic, or agriculture 550 32.1% 28.6%, 35.8%
a. Either some schooling or completed schooling.

children from poorer households were more likely to
be breastfed at the time of the survey, were more likely
to have been introduced to complementary foods at 6
to 8 months of age, were less likely to be eating a mini-
mally acceptable diet, were more likely to be breastfed
at 2 years of age, and were substantially less likely to
be taking multivitamin supplements than their peers
from wealthier households (all p < .05; data not shown).
The prevalence of acute malnutrition (wasting,
WLZ < –2) was low (approximately 5%) in study chil-
dren 6 to 23 months of age. Just over 26% of children
were stunted (LAZ < –2), and 18% were underweight
(WAZ < –2). Anemia affected 41.8% of children aged
6 to 23 months, but more than a quarter of the chil-
dren were only mildly anemic; moderate anemia was
somewhat less common (16% of children), and severe
anemia was rare. Iron deficiency was present in slightly
more than a quarter of children, and about three-
quarters of these cases manifested as iron-deficiency
anemia, meaning that almost half of the anemia in this
population of young children was explained by iron
deficiency. Vitamin A deficiency was present in 3.3%
of the study children.
Risk factors for stunting and wasting
In a first step, an extensive list of socioeconomic and
IYCF variables was assessed for crude associations with
stunting or wasting without consideration of possible
confounding. Because wasting was relatively uncom-
mon, none of the associations between wasting and
any potential risk factors were statistically significant,
and these analyses are not presented. Detailed results
of the analyses for stunting are presented in table 4. It
is noteworthy that many of the household economic
factors and mother’s education were significantly
associated with stunting, although the bivariate associa-
tions between stunting and morbidity indicators, and
stunting and the WHO core IYCF indicators were not
statistically significant. The only dietary factor with a
Infant and young child feeding practices in urban Philippines S23

TABLE 3. Characteristics of selected children

No. of Weighted
Characteristic children % or mean 95% CI
Demographic variables
Age (mo) (mean) 1,784 15.0 14.5, 15.4
Age group (mo) (%)
6–11.9 596 32.1% 27.9%, 36.6%
12–15.9 384 21.4% 18.8%, 24.3%
16–23.9 804 46.4% 42.2%, 50.8%
Sex (%)
Male 895 49.9% 47.0%, 52.9%
Female 889 50.1% 47.1%, 53.0%
Type of delivery (%)
Vaginal 1,633 90.2% 87.6%, 92.3%
Cesarean 149 9.8% 7.7%, 12.4%
No. of siblings (%)
0 544 31.7% 28.2%, 35.3%
1 472 27.8% 24.8%, 31.0%
2 318 16.6% 13.9%, 19.8%
3 184 9.7% 7.7%, 12.3%
4 127 7.8% 6.1%, 9.8%
≥5 139 6.4% 4.9%, 8.3%
Principal caretaker (%)
Mother 1,515 82.8% 79.1%, 86.0%
Father 48 3.4% 2.5%, 4.7%
Grandmother or grandfather 137 8.4% 6.2%, 11.4%
Other family member 66 4.6% 3.0%, 7.0%
Unrelated caretaker 13 0.8% 0.3%, 2.0%
Recent morbidity and current inflammation
Fever in past 2 wk (%)
Yes 601 33.4% 30.2%, 36.7%
No 1,183 66.6% 63.3%, 69.8%
Cough and fast breathing in past 2 wk (%)
Yes 306 12.3% 10.2%, 14.9%
No 1,478 87.7% 85.1%, 89.8%
Diarrhea in past 2 wk (%)
Yes 270 16.7% 14.2%, 19.6%
No 1,514 83.3% 80.4%, 85.8%
Elevated markers of inflammation (%)
None 1,274 74.0% 70.3%, 77.4%
CRP only 71 4.8% 3.4%, 6.8%
Both CRP and AGP 196 9.1% 7.3%, 11.3%
AGP only 226 12.1% 9.6%, 15.0%
Breastfeeding and complementary feeding indicators a
Breastfeeding initiated < 1 h after birth (all
children) (%)
Yes 915 48.5% 44.9%, 52.2%
No 703 51.5% 47.8%, 55.1%
Currently breastfeeding (all children) (%)
Yes 918 52.0% 48.4%, 55.5%
No 712 48.0% 44.5%, 51.6%

continued
S24 F. Rohner et al.

TABLE 3. Characteristics of selected children (continued)

No. of Weighted
Characteristic children % or mean 95% CI
Continued breastfeeding at 1 yr (children
12–14.9 mo) (%)
Yes 149 52.0% 43.1%, 60.9%
No 109 48.0% 39.1%, 56.9%
Introduction of complementary foods (chil-
dren 6–8.9 mo) (%)
Yes 286 91.3% 85.5%, 94.9%
No 54 8.7% 5.1%, 14.5%
Minimum dietary diversity met (all children)
(%)
Yes 1,067 57.7% 54.1%, 61.2%
No 717 42.3% 38.8%, 45.9%
Minimum meal frequency met (all children)
(%)
Yes 1,397 89.5% 87.1%, 91.6%
No 231 10.5% 8.4%, 12.9%
Diet meets minimum criteria for acceptability
(all children) (%)
Yes 692 58.2% 53.6%, 62.6%
No 507 41.8% 37.4%, 46.4%
Ate animal-source food in past 24 h (%)
Yes 1,634 88.0% 81.6%, 92.3%
No 150 12.0% 7.7%, 18.4%
Micronutrient supplementation
Current use of multivitamins (%)
Yes 1,221 70.5% 67.1%, 73.7%
No 562 29.5% 26.3%, 32.9%
Vitamin A supplementation in past 6 mo
(children ≥ 12 mo) (%)
Yes 781 62.9% 57.8%, 67.7%
No 317 37.1% 32.3%, 42.2%
Malnutrition
Weight-for-length z-score (mean) 1,778 –0.38 –0.48, –0.29
Wasting (%)
Severe 14 0.4% 0.2%, 1.2%
Moderate 84 4.7% 3.4%, 6.5%
None 1,654 93.3% 91.3%, 94.9%
Overweight 24 1.2% 0.6%, 2.3%
Obese 2 0.3% 0.1%, 1.2%
Length-for-age z-score (mean) 1,777 –1.19 –1.33, –1.06
Stunting (%)
Severe 142 7.3% 5.8%, 9.3%
Moderate 335 19.1% 16.3%, 22.3%
None 1,300 73.5% 69.8%, 77.0%
Weight-for-age z-score (mean) 1,780 –0.89 –1.00, –0.78
Underweight (%)
Severe 59 3.2% 2.1%, 4.9%
Moderate 255 14.3% 11.7%, 17.4%
None 1,466 82.5% 79.0%, 85.5%
continued
Infant and young child feeding practices in urban Philippines S25

TABLE 3. Characteristics of selected children (continued)

No. of Weighted
Characteristic children % or mean 95% CI
Micronutrient status
Hb concentration (g/L) (mean) 1,784 111 110, 112
Anemia (%)
None 1,018 58.2% 54.0%, 62.2%
Mild (Hb 100–109 g/L) 470 25.3% 22.0%, 28.8
Moderate (Hb 70–99 g/L) 293 16.3% 13.5%, 19.4%
Severe (Hb < 70 g/L) 3 0.3% 0.1%, 2.0%
Iron deficiency (after adjustment for inflam-
mation) (%)
Yes 442 27.9% 24.6%, 31.3%
No 1,325 72.1% 68.7%, 75.4%
Anemia (%)
Anemia with iron deficiency 301 18.7% 16.0%, 21.9%
Anemia without iron deficiency 458 23.1% 20.1%, 26.3%
No anemia 1,018 58.2% 54.1%, 62.2%
Vitamin A deficiency (after adjustment for
inflammation) (%)
Yes 146 3.3% 2.3%, 4.8%
No 1,621 96.7% 95.2%, 97.7%
AGP, alpha1-acid-glucoprotein; CRP, C-reactive protein; Hb, hemoglobin
a. See text in Methods section for summary definitions or Daelmans et al. [6] for detailed definitions.

TABLE 4. Bivariate relationships between stunting and various potential risk factors
Weighted % Adjusted chi-
Factor stunting square p value
Household socioeconomic status < .001
Poorest (class E) 44.4
Poor (class D) 25.5
Middle (class C) 10.7
Cooking fuel < .001
Kerosene, coal, wood, etc. 33.9
Electricity of natural gas 19.6
Safe drinking water < .001
Yes 32.0
No 20.6
Adequate sanitation facilities < .01
Yes 25.1
No 36.5
Mother’s age (yr) .43
< 25 24.9
25–29 29.4
≥ 30 25.8
Mother’s educational level < .001
None or preschool only 59.6
Elementary 35.9
High school or postsecondary 29.8
University or postgraduate 16.7
continued
S26 F. Rohner et al.

TABLE 4. Bivariate relationships between stunting and various potential risk factors
(continued)
Weighted % Adjusted chi-
Factor stunting square p value
Mother’s occupation .32
Unemployed 28.0
Unskilled, domestic, or agriculture 27.9
Sales or service 20.2
Professional, clerical, or skilled manual 21.3
Child’s age (mo) < .001
6–11.9 16.4
12–15.9 29.1
16–23.9 32.2
Child’s sex .78
Male 26.9
Female 26.1
No. of siblings .13
0 21.6
1 27.7
2 23.5
3 32.4
4 33.9
≥5 34.6
Child had fever in past 2 wk .07
Yes 31.0
No 24.2
Child had cough and fast breathing in past 2 .66
wk
Yes 28.0
No 26.2
Child had diarrhea in past 2 wk .62
Yes 28.2
No 26.1
Child has inflammation (CRP or AGP .48
elevated)
Yes 28.5
No 25.7
Breastfeeding initiated < 1 h after birth .11
Yes 29.0
No 23.9
Child currently breastfeeding .09
Yes 29.4
No 24.0
Child meets minimum dietary diversity .35
Yes 27.8
No 24.6
Child meets minimum meal frequency .40
Yes 27.2
No 23.6
Child’s diet is acceptable .14
Yes 30.1
No 26.4
continued
Infant and young child feeding practices in urban Philippines S27

TABLE 4. Bivariate relationships between stunting and various potential risk factors
(continued)
Weighted % Adjusted chi-
Factor stunting square p value
Child ate animal-source food in past 24 h .71
Yes 26.6
No 24.8
Child consumes multivitamins at least weekly .001
Yes 22.2
No 36.7
Child received vitamin A in past 6 mo .48
Yes 32.5
No 29.3
AGP, alpha1-acid-glucoprotein; CRP, C-reactive protein

statistically significant negative association with stunt-
ing was recent daily or weekly intake of multivitamin
supplements.
Logistic regression corroborated some of these find-
ings (table 5), confirming that a lower socioeconomic
status, the use of cheaper household cooking fuel,
older child age, and nonuse of multivitamins remained
significantly negatively associated with stunting after
accounting for the effects of the other variables in the
model.

TABLE 5. Logistic regression for stunting, anemia, iron deficiency, and vitamin A defi-
ciency as outcomes using factors with statistically significant associations
Variable Odds ratio 95% CI P value
Outcome: stuntinga
Socioeconomic group < .001
Poorest (class E) 4.8 2.4, 9.4
Poor (class D) 2.4 1.4, 4.4
Middle (class C) Referent —
Cooking fuel < .05
Kerosene, coal, wood, etc. 1.5 1.1, 2.2
Gas or electricity Referent —
Child’s age (mo) < .001
Change in odds with each month 1.08 1.04, 1.12
Multivitamin use daily or weekly < .05
No 1.5 1.0, 2.4
Yes Referent —
Outcome: anemiaa
Socioeconomic group < .05
Poorest (class E) 1.9 0.91, 3.8
Poor (class D) 0.85 0.53, 1.3
Middle (class C) Referent
Cooking fuel < .01
Kerosene, coal, wood, etc. 1.6 1.2, 2.3
Gas or electricity Referent
Fever in past 2 wk < .05
Yes 1.5 1.0, 2.4
No Referent —
continued
S28 F. Rohner et al.

TABLE 5. Logistic regression for stunting, anemia, iron deficiency, and vitamin A defi-
ciency as outcomes using factors with statistically significant associations (continued)
Variable Odds ratio 95% CI P value
Inflammation (elevated CRP or AGP) .07
Yes 1.4 0.98, 2.1
No Referent
Child’s age (mo) < .01
Change in odds with each month 0.93 0.89, 0.98
Currently breastfeeding < .001
Yes 3.1 2.1, 4.6
No Referent —
Outcome: iron deficiencya
Mother’s educational level < .001
None, preschool, or elementary school 2.2 1.2, 4.0
High school or postsecondary 3.0 1.9, 4.5
University or postgraduate Referent —
Fever in past 2 wk < .05
Yes 0.64 0.43, 0.94
No Referent —
Inflammation (elevated CRP or AGP) < .001
Yes 0.50 0.36, 0.70
No Referent
Currently breastfeeding < .001
Yes 2.0 1.5, 2.8
No Referent —
Multivitamin use daily or weekly < .01
No 1.5 1.1, 2.0
Yes Referent —
Outcome: vitamin A deficiencya
Cooking fuel < .001
Kerosene, coal, wood, etc. 7.5 2.5, 22.2
Gas or electricity Referent —
Inflammation (elevated CRP or AGP) < .001
Yes 3.6 1.8, 7.6
No Referent
Breastfeeding initiated < 1 h after birth < .05
Yes 2.5 1.1, 5.6
No Referent —
AGP, alpha1-acid-glucoprotein; CRP, C-reactive protein
a. Initial models included the following additional variables, which were excluded during back-
wards elimination: Stunting: use of safe drinking water, adequate sanitation facilities, mother’s
educational level, number of siblings, presence of fever in past 2 weeks, currently breastfeeding,
breastfeeding initiated < 1 hour after birth, and dietary acceptability. Anemia: use of safe drinking
water, adequate sanitation facilities, mother’s educational level, mother’s occupation, number of
siblings, minimum dietary diversity, minimum meal frequency, minimum dietary acceptability,
ate animal-source food, and daily or weekly multivitamin consumption. Iron deficiency: socio-
economic group, predominant type of cooking fuel used, adequate sanitation facilities, mother’s
occupation, number of siblings, child’s age, presence of fever in past 2 weeks, ate animal-source
food. Vitamin A deficiency: socioeconomic group, use of safe drinking water, number of siblings,
currently breastfeeding, minimum dietary diversity, daily or weekly multivitamin consumption.
None of the interaction terms were statistically significant in the final models.
Infant and young child feeding practices in urban Philippines S29

Risk factors for anemia, iron deficiency, and vitamin
A deficiency
Household socioeconomic status, type of fuel used
in the household, and sanitation facilities were all
significantly associated with anemia, iron deficiency,
and vitamin A deficiency, with lower prevalence rates
among children from wealthier households, households
using more expensive fuel sources (gas or electricity),
and households with adequate sanitation facilities
(table 6). Households with safe drinking water had
a higher prevalence of anemia, iron deficiency, and
vitamin A deficiency, although the association was
significant only for anemia. Mother’s age was not sig-
nificantly related to the prevalence of anemia or iron
deficiency, but the association with vitamin A deficiency

TABLE 6. Bivariate relationships between anemia, iron and vitamin A deficiency and various risk factors
Anemia Iron deficiency Vitamin A deficiency
Weighted Weighted Weighted
Factor % pa % pa % pa
Household socioeconomic status < .001 < .001 < .05
Poorest (class E) 62.8 33.1 6.5
Poor (class D) 38.8 30.2 2.9
Middle (class C) 31.5 11.9 1.6
Predominant household cooking fuel < .001 < .001 < .001
Kerosene, coal, wood, etc. 50.6 33.9 6.2
Natural gas or electricity 33.8 22.4 0.7
Household has safe drinking water < .01 .17 .08
Yes 46.9 29.8 4.3
No 36.3 25.5 2.4
Household has adequate sanitation <.01 < .01 .25
Yes 39.7 26.1 3.0
No 56.9 40.1 5.4
Mother’s age (yr) .23 .57 .57
< 25 44.2 28.3 4.1
25–29 42.7 25.6 3.0
≥ 30 38.8 29.1 2.8
Mother’s educational level < .001 < .001 .20
None or preschool only 41.8 1.0 0.0
Elementary 49.7 30.7 5.1
High school or postsecondary 47.6 34.4 3.9
University or postgraduate 28.5 14.9 1.7
Mother’s occupation < .01 < .05 .39
Unemployed 44.6 30.3 3.7
Unskilled, domestic, or agriculture 45.6 33.4 2.0
Sales or service 36.4 19.1 3.8
Professional, clerical, or skilled 14.6 8.8 0.0
Child’s age (mo) < .01 .36 .62
6–11.9 49.9 24.7 2.9
12–15.9 45.5 31.0 2.9
16–23.9 34.6 28.6 3.9
Child’s sex .66 .25 .58
Male 41.1 29.6 3.6
Female 42.6 26.1 3.0
continued
S30 F. Rohner et al.

TABLE 6. Bivariate relationships between anemia, iron and vitamin A deficiency and various risk factors (continued)
Anemia Iron deficiency Vitamin A deficiency
Weighted Weighted Weighted
Factor % pa % pa % pa
No. of child’s siblings < .05 .07 < .05
0 33.5 24.0 2.6
1 43.4 27.6 2.8
2 45.9 33.0 5.0
3 46.3 21.5 7.1
4 44.4 38.1 0.3
≥5 55.7 31.6 3.2
Child had fever in past 2 wk < .01 < .05 .92
Yes 50.3 21.9 3.4
No 37.6 30.8 3.3
Child had cough and fast breathing in .19 .17 .39
past 2 wk
Yes 36.2 22.3 4.6
No 42.6 28.6 3.2
Child had diarrhea in past 2 wk .93 .50 .41
Yes 41.5 30.1 4.3
No 41.9 27.4 3.1
Child has inflammation (CRP or AGP < .01 .001 < .001
elevated)
Yes 50.3 19.4 7.4
No 38.9 30.8 1.9
Breastfeeding initiated within 1 h of birth .48 .86 < .01
Yes 44.0 28.7 5.5
No 41.6 29.3 1.7
Child currently breastfeeding < .001 < .001 .15
Yes 58.2 35.7 4.2
No 26.1 21.4 2.7
Child meets minimum dietary diversity .06 .66 .13
Yes 38.8 27.3 3.9
No 46.0 28.6 2.6
Child meets minimum meal frequency < .01 .88 .92
Yes 40.8 28.9 3.5
No 59.5 28.0 3.7
Child’s diet is acceptable < .01 .62 .26
Yes 43.6 30.1 5.1
No 58.7 33.7 3.5
Child ate animal-source food in past 24 h < .001 .08 .84
Yes 39.8 27.1 3.3
No 70.4 39.0 3.7
Child consumes multivitamins at least < .01 < .01 < .01
weekly
Yes 38.2 24.6 2.4
No 50.6 35.7 5.5
Child received vitamin A in past 6 mo .69 .35 .76
Yes 39.6 30.9 3.2
No 37.8 27.1 3.6
a. Adjusted chi-square p value.
Infant and young child feeding practices in urban Philippines
was marginally significant. Maternal educational level
and current occupation were significantly associated
with anemia, iron deficiency, and vitamin A deficiency.
Children of mothers with a college-level education or
a professional, clerical, or skilled occupation had a sig-
nificantly lower prevalence of these deficiencies. The
low prevalence seen in children of mothers with no
education is probably due to the very small number of
children in this category. Inflammation was significantly
associated with anemia, iron deficiency, and vitamin A
deficiency, with positive associations for anemia and
vitamin A deficiency and a negative association for
iron deficiency. Other child-related factors, such as age,
number of siblings, and recent fever were significantly
associated with anemia, but not with iron or vitamin A
deficiency. Symptoms of morbidity were not associated
with micronutrient deficiencies.
The observed bivariate associations between feed-
ing indicators and micronutrient status were relatively
weak and sporadic. Children who were breastfed at the
time of the survey had a substantially higher prevalence
of both anemia and iron deficiency. On the other hand,
children with early initiation of breastfeeding had a
statistically significantly higher prevalence of vitamin
A deficiency than children without early initiation of
breastfeeding. Meeting the minimum criteria for meal
frequency and acceptability of child’s diet was associ-
ated with a lower prevalence of anemia. Not surpris-
ingly, daily or weekly consumption of multivitamin
supplements was significantly associated with a higher
prevalence of anemia, iron deficiency, and vitamin A
deficiency. Finally, there were no associations between
receiving vitamin A supplementation in the prior 6
months and any micronutrient deficiency investigated
in this study.
As with stunting, logistic regression demonstrated
the strongest independent association between house-
hold socioeconomic status and anemia and iron
deficiency (table 5). Children presenting with inflam-
mation (as measured by elevated AGP or CRP) had
a significantly higher risk of concurrent vitamin A
deficiency, whereas inflammation-positive children had
a lower risk of concurrent iron deficiency; for anemia,
the significance level was borderline (p = .07), with a
higher anemia prevalence for children with inflam-
mation. The mother’s educational level influences the
risks of both anemia and iron deficiency; however,
there was no dose–response relationship between level
of education and level of deficiency. Breastfed children
were substantially more likely to be anemic or iron defi-
cient, even after controlling for socioeconomic status,
maternal education, and child’s age (anemia) and mul-
tivitamin use (iron deficiency). Children who lived in
households using cheaper liquid or solid cooking fuels
and those with early initiation of breastfeeding had a
significantly higher prevalence of vitamin A deficiency
than those with later onset of breastfeeding.
S31
Discussion
A Demographic and Health Survey conducted in 2008
revealed that many young children in the Philippines
were not being fed according to internationally rec-
ommended guidelines [1]. Based on these and earlier
findings, a consortium of agencies was established to
improve breastfeeding practices among young children
and to increase timely introduction of appropriate
complementary foods. The survey described here was
undertaken to establish a baseline for these interven-
tions, and at the time of writing, implementation of
these interventions has begun.
This is a cross-sectional study, and the findings
should therefore be interpreted cautiously when formu-
lating conclusions about cause–effect relationships. The
UNICEF framework, however, provides a useful logical
model for interpretation of our data. This framework
consists of basic, underlying, and direct causes of mal-
nutrition. Household socioeconomic status is related
to many of the underlying causes, which include access
to food, caring practices, hygiene environment, and
healthcare utilization. In our data, socioeconomic
status had an important association with the risks of
children’s being stunted, anemic, or iron or vitamin
A deficient; children from poorer households were
more prone to suffer from these conditions. This has
been previously shown in the analysis of large datasets
[14], in which socioeconomic status had a particularly
strong relationship with child nutritional status in
urban (as opposed to rural) households [15]. The direct
causes of stunting, as with other causes of malnutrition
shown in the UNICEF framework, are poor dietary
intake and high incidence rates of diseases. Some of
the intermediate factors, both underlying and immedi-
ate causes in the UNICEF framework, through which
socioeconomic status may affect nutritional status were
measured in our survey using variables such as access
to food, access to safe drinking water and sanitation
facilities, and caring and feeding practices, which may
also be influenced by maternal education and occupa-
tion. For example, poor households may have limited
access to safe water and sanitation, increasing the risk
of diarrheal disease, or may lack the purchasing power
to provide a sufficiently varied diet.
Although mother’s education has long been known
to have a major effect on child nutritional status [16],
it was associated only with iron deficiency in our study.
Maternal education may operate independently from
overall household socioeconomic status by improv-
ing mother’s caring practices for young children [16],
or it may merely raise the socioeconomic status of
the household without having an independent effect
through other mechanisms [17–19]. Our study seems
to support the latter hypothesis, given the lack of
association between indicators of caring practices
and stunting. Yet, the ability of this study to detect
S32
an association between maternal education and child
nutritional status or to distinguish among the various
mechanisms through which maternal education influ-
ences child nutritional status is handicapped by the
lack of variability in maternal education found in this
survey sample; more than 90% of mothers had at least
a high-school education.
Stunting is a more complex nutritional phenomenon
than vitamin A or iron deficiency. Although access
to fortified food and/or micronutrient supplements
can prevent specific micronutrient deficiencies, these
measures may only partially address the range of
nutrient deficiencies that underlie stunting. The fact
that socioeconomic status remained associated with
stunting but not with vitamin A and iron deficiencies
in multiple regression analyses indicates that the direct
and underlying factors as measured in this survey were
not completely able to explain the variation observed
in stunting. Since stunting develops over a long period
of time, starting at conception, current dietary intake
may not adequately measure the adequacy of nutrient
supply over the entire period. If this is true, socioeco-
nomic status may be a better proxy of access to nutri-
tious foods and hence nutrient intake.
Inflammation was positively associated with anemia
and vitamin A deficiency, whereas the association was
negative for iron deficiency. In the case of anemia,
this could be ascribed to anemia of chronic disease
[20], which develops from long-standing, low-level
inflammation. The negative association of inflamma-
tion with iron deficiency is somewhat more surprising,
as one would expect iron metabolism to be disturbed
during inflammation [21]. In the data we present, we
have adjusted ferritin concentrations for inflammatory
responses, but it may be that these adjustments are not
sufficient to counterbalance ferritin’s function as an
acute-response protein.
Most of the IYCF indicators were not significantly
associated with stunting, anemia, iron deficiency, or
vitamin A deficiency. These indicators are meant to
provide cross-sectional assessments of behaviors in
the population; they have major drawbacks when
used as measures of individual-level exposure to risk.
For example, they do not include information about
the quantity or frequency of food consumption over a
longer period of time. As a result, our findings could
be influenced by misclassification bias, which would
weaken the observed association between IYCF behav-
iors and malnutrition. In addition, because our survey
had a relatively small sample size, we may have failed
to achieve the power needed to detect a statistically
significant association between dietary factors and
nutritional outcomes, such as dietary diversity, which
have been shown to be significant in much larger
studies examining these factors [22, 23]. Regardless,
the confidence intervals for the odds ratios for dietary
diversity and stunting from our survey (analysis not
F. Rohner et al.
shown) overlap with the estimates from these other
studies, indicating that our survey’s findings are not
incompatible with those of other studies.
Children who were currently breastfed were more
likely to be anemic or iron deficient. This has been
repeatedly shown in previous studies, with the hypoth-
esis being that after 6 months of the child’s life, iron
stores from birth are exhausted and the low iron
content of breastmilk does not provide sufficient iron
to the child, although breastfeeding might partially
displace more iron-rich foods [24]. The mean age of
the children in the sample was 15 months, and at that
age, breastmilk (which has a very low iron content), if
it is replacing other iron-rich foods, may not provide
sufficient amounts of dietary iron. In addition, moth-
ers of children who are not healthy or who are growing
poorly (and therefore are more likely to be anemic)
may breastfeed their children longer—a form of reverse
causation, as demonstrated in other studies [25].
Current consumption of multivitamin preparations,
including syrups, tablets, or drops, was associated with
a reduced prevalence of stunting and current iron
deficiency. This finding should be further investigated
in future studies, and detailed questionnaire modules
should be incorporated into nutrition surveys to
assess the frequency, dosing, and type of multivitamin
preparations consumed by young children. In addi-
tion, analyses should characterize which households
use such preparations, as multivitamin use not only is
an indicator of micronutrient intake but may also be
an indicator of socioeconomic status. Furthermore,
a more in-depth module on the use of other “forti-
fied” foods, such as micronutrient powders, should be
included; this could possibly expand to consumption of
iron-fortified foods or supplements during pregnancy.
In our study, the number of caregivers who reported
using micronutrient powders was too small for analysis.
Both use of cheaper cooking fuel and nonuse of
multivitamin preparations were associated with several
outcomes in this study. Although neither of these fac-
tors was directly used to assess socioeconomic status,
they are linked to socioeconomic status (results not
shown). In spite of this association, our analysis showed
that both factors remained significantly associated with
several nutrition outcomes after accounting for the
effect of socioeconomic status in regression models.
The reason for an association between multivitamin
use and lower prevalence of micronutrient deficiencies
is somewhat self-evident. However, the association
between the type of cooking fuel and nutrition out-
comes is less clear. Previous studies have shown higher
stunting and anemia prevalence in households using
lower-quality fuels or open fires [26, 27]. As was done
in our study, the data included in these studies were
derived from questions asked about the usual type of
fuel used for cooking during interviews carried out in
cross-sectional surveys. The authors of the studies did
Infant and young child feeding practices in urban Philippines
not propose a mechanism for this association; however,
a study in India [19] ascribed 31% of moderate and
severe anemia and 37% of severe stunting to biofuel
smoke. Although causality cannot be ascribed to envi-
ronmental smoke, this relatively strong and consistent
association and potential for major contribution to
the prevalence of poor nutrition certainly supports
the need for further investigation, perhaps with better
measurements of household smoke exposure and
stronger study designs.
This survey has some limitations in that it was not
nationally representative. Instead, it aimed to gather
information from poorer urban dwellers in the Philip-
pines and therefore could explore associations only in
this select subgroup of children. Also, as previously
stated, the survey was cross-sectional; therefore, the
observed associations do not provide strong evidence
of causality. They do, however, provide information on
smaller or greater risk and the general direction of the
observed relationships, identifying some variables that
may contribute to chronic malnutrition and micronu-
trient deficiencies. One advantage of cross-sectional
studies is that they can collect a broad range of data
from a large number of children that may better reflect
associations in the real world than data collected via
experimental designs.
Conclusions
Poverty, reflected by low socioeconomic status indi-
cators, was strongly associated with child stunt-
ing, anemia, and iron and vitamin A deficiency in a
cross-sectional survey of young children in the urban
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Acknowledgments
We thank the children and their mothers and legal
caretakers for participation and assistance in the
survey. We would also like to acknowledge the dis-
trict health authorities for their support in facilitating
fieldwork.
UNICEF, the Global Alliance for Improved Nutri-
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provided financial, technical, or in-kind contributions
to this study.
None of the authors have conflicts of interest to
declare.
FR, BAW, MAOL, PR-S, and OPS designed the
study; MAOL, PR-S, and OPS performed the research;
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