A. Balalian et al. BMC Nutrition (2017) 3:85 DOI 10.1186/s40795-017-0204-9 RESEARCHARTICLE Open Access Prevalence and determinants of stunting in a conflict-ridden border region in Armenia - a cross-sectional study Arin A. Balalian1,2*, Hambardzum Simonyan1, Kim Hekimian3, Richard J. Deckelbaum3 and Aelita Sargsyan1 Abstract Background: Despite global efforts, stunting remains a public health problem in several developing countries. The prevalence of stunting among 0- to 5-year-old children in Armenia has increased from 17% in 2000 to 19% in 2010. A baseline study was conducted among preschool children in Berd, a region near the northeastern border of Armenia that has experienced intermittent military tension for over 20 years. Methods: We conducted a cross-sectional study including 594 children aged 6-month- 6 years old and their caregivers in our analysis, to assess the prevalence and determinants of stunting. We calculated the anthropometric measurements and hemoglobin levels of children; analyzed children’s stool and conducted a survey with children’scaregivers.We employed the hierarchical logistic regression model to explore the predictors of stunting among 25–72 months old children and multivariable logistic regression models to investigate the predictors of stunting among 6–24 months old children. Individual and residence level variables were included in the models including anemia, minimum dietary diversity, mothers’ height, the overall duration of breastfeeding, birthweight, child’s history of diarrhea and mean socio-economic score. Results: The prevalence of stunting was significantly higher among the 6–24 months old children (13.3%) compared to the children aged 25–72 months old (7.8%). We did not find any differences in the prevalence of stunting by place of residence in either age group. The 6–24 months old children who consumed at least four food groups during the previous day (minimum dietary diversity) had 72% lower odds of being stunted (p < 0.05). Each kilogram increase in birthweight was associated with 76% lower odds of being stunted (OR = 0.24, p < 0.01). Mother’sheightsignificantly decreased the odds of stunting among the children 25–72- months old (OR = 0.86, p < 0.001). BMI was also a significant predictor of stunting among both age-groups. Conclusions: The study results highlight the significance of mother’s height, birthweight, and adequate complementary feeding to reduce stunting. Further studies are needed to determine the possible association of anemia and stunting with the ongoing conflict in the region, as well as socioeconomic conditions and food insecurity in the region. Keywords: Stunting, Conflict, Armenia, Infant and child nutrition, Growth * Correspondence: [email protected]; [email protected]; [email protected] 1Fund for Armenian Relief of America, #22 Khorenatsi Street, Yerevan, Armenia 2Department of Epidemiology, Columbia University, Mailman School of Public Health, Room #1616, 722 W 168th Street, New York, NY 10032, USA Full list of author information is available at the end of the article © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. A. Balalian et al. BMC Nutrition (2017) 3:85 Page 2 of 13 Background According to the ADHS, the prevalence of stunting in Several studies have found that protracted conflicts have 2010 was 16.1% in the Tavush province [16] which was an adverse impact on health [1–3]. Current on-going one of the regions with the highest prevalence of stunt- conflicts in the former Soviet states, such as Ukraine, ing in Armenia. Frequent tensions and skirmishes along and in the nearby Middle East certainly have an impact the Armenian–Azerbaijani border have increased in on childhood health [4, 5]. Armenia is one such conflict- recent years [31–33], resulting in diminished agricultural ridden former Soviet country, located in the Caucasus capacity and affecting socioeconomic conditions in this region. Long-standing military tensions may exacerbate region. Tensions are intense in the Berd region in par- health and nutrition status of vulnerable populations ticular, because of its proximity to the border between affected by such circumstances, particularly young chil- Armenia and Azerbaijan. dren [6]. The growing trend of stunting in Armenia necessitates According to the World Health Organization (WHO), a thorough investigation to understand its risk factors to 54% of all child deaths are associated with undernutri- inform policies and interventions to reverse the trend. tion [7]. Despite global efforts to achieve the Millennium Although the determinants of stunting have been well Development Goals, the percentage of stunted children investigated in several studies, the specific precursors of under age five remains high. Since 1990, there has been stunting might vary among different countries and a steady decrease in stunting worldwide; however, it is regions [34]. This different pattern is evident among estimated that globally in 2016, 24% of children under former Soviet countries [30, 35]. Therefore, it is import- age five were still stunted [8, 9]. Stunting during child- ant to study the risk factors responsible for nutritional hood can lead to reduced immunity, increased suscepti- problems of children specific to Berd region in Armenia. bility to non-communicable diseases, impaired physical The main aim of this study was to determine the and mental development, and reduced productivity [10]. prevalence and determinants of stunting among pre- Several factors influence stunting, including the socio- school children in Berd city and its seven surrounding economic status of the household, parents’ education, rural communities, a vulnerable border region in the anemia, soil-transmitted helminths (STH) infections, Tavush province in the Republic of Armenia, which is diarrheal infections, dietary intake and complementary itself a low-middle income country. We specifically feeding [11–22]. Short overall duration of breastfeeding, explored if there are significant differences in the preva- as well as the late introduction of appropriate solid lence of stunting among the children 6–24 months and foods, have both been associated with stunting in many 25–72 months old. We also examined if the prevalence studies [18, 23–26] Birth outcomes such as low birth of stunting in each age group was different by place of weight and birth length are also important factors residence. We further investigated the influence of that are associated with higher prevalence of stunting anemia, soil-transmitted helminths, feeding practices, [24, 27, 28]. dietary intake, maternal and household characteristics In a study conducted in Sri Lanka, maternal height and birth outcomes on stunting among children 6– was inversely related to the prevalence of stunting [18]. 24 months and 25–72 months old. Low birthweight was associated with higher rates of stunting in the same study. Socioeconomic status of the Methods family was associated with stunting in among school Study design children in Nigeria [29]. In another study conducted in This cross-sectional study included anthropometric (height, Nigeria, children who did not receive timely comple- weight) measurements, blood tests to measure hemoglobin mentary feeding and children with less than minimum (HgB) levels of 6-month to 6-year-old children, and stool food diversity had higher odds of being stunted. [22]. analysis for intestinal STH in 12-months to 6-year-old chil- There are limited data regarding infant and child nutri- dren. The survey also included a questionnaire for care- tion status in the Republic of Armenia. The Armenian givers (mainly mothers) to understand the determinants of Demographic and Health Survey (ADHS), conducted malnutrition in the target communities. The study was every 5 years, is the primary source of information regard- designed and conducted from September 2013 to March ing nutrition and child growth patterns. According to the 2014. 2010 ADHS, the prevalence of stunting among 0- to 5- year-old children increased to 19% from 17% in 2000 [16]. Study population A recent study conducted in Yerevan, the capital of The study population for the anemia analysis and an- Armenia, identified the prevalence of stunting as 17.9% thropometric measurements included all 6-month to among 5- to 17-month-old children, which is close to the 6 year-old children living in the city of Berd and seven 2010 ADHS estimated percentage of around 17.3% in surrounding rural communities (Chinchin, Varagavan, Yerevan [16, 30]. Paravakar, Verin Caghkavan, Nerkin Karmiraghbyur, A. Balalian et al. BMC Nutrition (2017) 3:85 Page 3 of 13 Tavush, and Aygepar). The only exclusion criteria were Parents were instructed to collect the first morning stool if the child was diagnosed with a blood coagulation or of their children. They were also instructed to refrigerate neurological disease; however, no child in our sample the stool samples and transport them to the nearest local met the exclusion criteria.