Economics and Human Biology 8 (2010) 188196

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Economics and Human Biology

journal homepage: http://www.elsevier.com/locate/ehb

Disentangling nutritional factors and household characteristics related

to child stunting and maternal overweight in Guatemala
Jounghee Lee a, Robert F. Houser a, Aviva Must a,b, Patricia Palma de Fulladolsa c,
Odilia I. Bermudez a,b,*
a
Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA 02111, United States
b
Department of Public Health and Community Medicine, Tufts University, Boston, MA 02111, United States
c
Regional Food and Nutrition Security Program for Central America, Boulevard del Hipodromo No. 523, Colonia San Benito, San Salvador, El Salvador

A R T I C L E I N F O A B S T R A C T

Keywords: The aim of this study was to identify nutritional factors and households characteristics
Child stunting associated with child stunting, maternal overweight and the familial coexistence of both
Maternal overweight types of malnutrition. In Guatemala, 2000, with nationally representative data, we
Double burden of malnutrition selected 2261 households with at least one child aged 1260 months and his/her mother.
Guatemala Nutritional status was assessed in children (e.g., stunting as height-for-age Z-score < 2)
Nutrition and mothers (e.g., overweight as body mass index  25 kg/m2) and identied the presence
of both, child stunting and maternal overweight in the same household (SCOM). With
logistic regression models we assessed the association of the malnutrition indicators with
individual and household socio-economic and health characteristics. SCOM was identied
in 18% of households. Socio-economic status (SES) of SCOM households was signicantly
lower than SES of households with non-stunted children. SCOM households, compared to
those with normal-stature children and normal weight mothers, were more likely to have
mothers of short stature (adjusted odds ratio-OR  95% CI = 3.1 (2.14.7)), higher parity (1.2
(1.11.3)), currently working (1.7 (1.12.6), and self-identied as indigenous (2.0 (1.33.1)).
Factors associated with stunting in children such as poverty, maternal short stature and
indigenousness, were predictors of SCOM. These ndings support the notion that SCOM is an
extension of the malnutrition spectrum in the most disadvantaged population groups in
countries that are in the middle of their nutrition transitions such as Guatemala. At the same
time it revealed that these populations are already in the stage of chronic, nutrition related
diseases associated with less physical activity and more access to highly processed foods of
low cost, high dietary energy and low nutrient density in important population groups. The
challenge for the decision makers and service deliverers is to guide SCOM households to deal
equally with both extremes of the malnutrition continuum.
2010 Elsevier B.V. All rights reserved.

Abbreviations: SCOM, stunted child and overweight mother; SCNM,
stunted child and normal weight mother; NCOM, non-stunted child and
overweight mother; NCNM, non-stunted child and normal weight
mother.
* Corresponding author at: Tufts University School of Medicine,
Department of Public Health and Community Medicine, 136 Harrison
Avenue, Boston, MA 02111, United States. Tel.: +1 617 636 2194;
fax: +1 617 636 4017.
E-mail address: odilia.bermudez@tufts.edu (O.I. Bermudez).
1. Introduction
The seemingly paradoxical phenomenon of the familial
coexistence of child stunting and maternal overweight is
an emerging nutrition problem in Latin America, particu-
larly in Guatemala. Garret and Ruel examined the
proportion of stunted children and overweight mothers
(SCOMs) within a single household in 36 countries on 3
continents, limiting subject criteria to child and mother

1570-677X/$ see front matter 2010 Elsevier B.V. All rights reserved.
doi:10.1016/j.ehb.2010.05.014
 J. Lee et al. / Economics and Human Biology 8 (2010) 188196
pairs within the same household. Of the four countries in
the world that had a prevalence that exceeded 10%, three
are in Latin America: Nicaragua 10%; Bolivia 11%, and
Guatemala 13% (Garrett and Ruel, 2003). In a subsequent
worldwide study with data from 42 countries, by the same
researchers, Guatemala was found to have the highest
prevalence (16%) of SCOM pairs (Garrett and Ruel, 2005). A
large, multi-country study conducted by Jehn and Brewis
also revealed that out of 18 countries Guatemala has the
highest rate of the dual burden of malnutrition measured
as the dyad underweight child, overweight mother
(prevalence of 5.3%) or as stunted child and overweight
mother with a prevalence of approximately 23% (Jehn and
Brewis, 2009). Little is known, however, about individual
and household characteristics associated with SCOM pairs
in countries like Guatemala, where the high prevalence of
SCOM seems paradoxical.
Predictors of child stunting and adult obesity, separately,
have already been identied (Frongillo et al., 1997; Vitolo
et al., 2008; Brennan et al., 2009; Sidik and Rampal, 2009),
but only few studies have investigated the predictors of the
familial dual burden of malnutrition (coexistence of child
stunting and maternal overweight). In the study mentioned
above, Jehn and Brewis combined the Demographic and
Health Survey data sets from 18 low and lower-middle
income countries in four regions (Northern Africa, Sub-
Saharan Africa, South Asia and South America) (Jehn and
Brewis, 2009). They found that the occurrence of under-
weight child and overweight mother (UCOM) pairs was
signicantly associated with older maternal age, less formal
education, more children within the same household and
urban residence, compared with the occurrence of normal
weight child and normal weight mother (NWC/NM) pairs.
Except for urban residence, signicant risk factors asso-
ciated with stunted child and overweight mother (SCOM)
pairs were similarly compared with those for non-stunted
child and normal weight mother (NCNM) pairs.
There are predictors of SCOM households, which involve
a combination of factors at the individual level and the
household level. For example, one study investigated
household factors associated with familial coexistence of
child protein-energy malnutrition and maternal overweight
in a small sample (n = 148 households) from poor urban
areas in Benin, West Africa (Deleuze Ntandou Bouzitou et al.,
2005). The main ndings of this study were that low food
diversity and poor household sanitation were associated
with the high prevalence of child malnutrition and maternal
overweight within the same household. However, this study
grouped the different types of child undernutrition (child
stunting, child underweight and child wasting) together
into one group, making it difcult to identify the factors
associated with the specic type of malnutrition (e.g.,
chronic or current undernutrition) of the child. It would
seem that further investigations of individual and house-
hold characteristics associated with SCOM households in
Guatemala are needed. A national, representative data set
must be employed in order to be useful in Guatemala.
However, although generalization beyond Guatemala may
not be possible, conrming suggested predictors of SCOM, or
uncovering additional ones may contribute to inform the
decision-making process. We aimed to address the strate-
189
gies to contain or halt the increasing trend of SCOM observed
in countries that, like Guatemala, are in the midst of their
nutrition transition.
The main purpose of our study was to examine
combinations of maternal, child, and household risk
factors related to the existence in the same household of
child stunting and maternal overweight in Guatemala. To
fully explain the familial coexistence of child stunting and
maternal overweight, this study examined what predictors
were related to child stunting and maternal overweight
separately, and, secondly, determined common and
independent predictors of the familial coexistence of child
stunting and maternal overweight.
2. Methods
The Living Standards Measurement Study (LSMS) was
carried out in Guatemala in the year 2000, with 7276
households surveyed (World Bank, 2000). LSMS used a
complex survey design with a nationally representative
sample of Guatemalans. Additionally, LSMS collected
anthropometric information for all members of each
household (37,771 individuals).
For this study, we rst selected 4595 children between
12 and 60 months old. Of this subset, we rst excluded 652
children that did not meet our selection criteria: 153 did not
live with the mother, 290 children lived in households with
more than one pairing of child and mother, and 209 children
were outliers based on the World Health Organization
(WHO) child growth standards (World Health Organization,
2006). This reduced the sample to 3943 children. After
selection of one child at random in households with more
than one child between 12 and 60 months of age, we had
2915 households with child and mother pairs, from where
we further excluded 587 households including: mothers
who did not have anthropometric data (n = 54), were
pregnant (n = 328), had given birth <3 months previous
to the survey (n = 155), were <18 or >49 years old (n = 31),
or had BMI outliers (<6.2 or >42.6 BMI) (n = 19). Further-
more, 6 households were excluded because information on
maternal education (n = 3) or exclusive breastfeeding (n = 3)
was missing. We also excluded underweight mothers
(<18.5 BMI) (n = 61) to avoid any potential problem with
data interpretation occurring from inclusion of underweight
mothers because our comparison groups were formed with
either overweight or normal weight mothers (Jehn and
Brewis, 2009). The nal analytic sample was 2261 child and
mother pairs for whom full data were available. For this
study, we obtained ethical approval from the Tufts Medical
Center/Tufts University Institutional Review Board.
2.1. Outcome measures
2.1.1. Nutritional status of the child
Age and height were used to calculate height-for-age Z-
scores (HAZ) for children that were compared with the
WHO standards by using the WHO Anthro 2005 software
program (World Health Organization, 2005). As indicated
before, we excluded 209 children dened as outliers based
on the WHO child growth guidelines (World Health
Organization, 2006), which for height-for-age are dened
190 J. Lee et al. / Economics and Human Biology 8 (2010) 188196
as Z-scores below 6 SD and above +6 SD. All children were
categorized into 2 groups as stunted (HAZ < 2 SD), and
normal weight or non-stunted (HAZ  2 SD).
2.1.2. Nutritional status of the mother
Body mass index (BMI) of mother was calculated by
dividing their weight in kilograms by her height in meters
squared (kg/m2). All mothers were divided into two
categories: overweight (BMI  25) or normal weight
(18  BMI < 25) following the classication criteria set
by the WHO (World Health Organization, 2000).
2.1.3. Types of child and mother pairs
Based on their respective nutritional assessment for
chronic undernutrition (stunting) and overweight, all child
and mother pairs were classied into one of four categories
as follows: stunted child and overweight mother (SCOM),
stunted child and normal weight mother (SCNM), non-
stunted child and overweight mother (NCOM), and non-
stunted child and normal weight mother (NCNM).
2.2. Exposure measures
2.2.1. Child factors
Child age was classied into 4 groups: 1224, 2536, 37
48, and 4960 months. Sex of the child was classied as a
dichotomous variable with a value of 1 if the sex of the child
was male and a value of 0 if the sex of the child was female.
As a proxy for health status of the children, we used two
types of information: vaccination and presence of diarrhea or
respiratory disease during the month preceding the inter-
view. We assumed that those fully vaccinated were more
likely to be in good health than those with incomplete or
missing vaccinations. We used the vaccination schedule
guidelines recommended by the Pan American Health
Organization as follows: one dose of BCG at birth, 3 doses
of DTP at 2, 4, and 6 months, 3 doses of polio at 2, 4, and 6
months, and 1 dose of measles at 9 months (Pan American
Health Organization, 2009). After determining whether the
child was current with his/her vaccination schedule for
tuberculosis (BCG), polio, measles and for diphtheria,
whooping cough, and tetanus (DTP), we created a summary
score, which was further recoded as a dichotomous variable
taking the value of 1 if the child was fully vaccinated for all the
vaccines listed before. Otherwise we assigned 0 if the child
was partially vaccinated or did not receive any vaccination.
Each mother of the index children reported whether
their children had a diarrhea or a respiratory illness within
the last month. Each of these diseases was recoded as
dichotomous variables respectively. A respiratory disease
included cold, cough, bronchitis, breathing trouble or any
respiratory infection.
Length of exclusive breastfeeding was another pre-
dictor variable used in this study. The total number of
months on exclusive breastfeeding was categorized into
three levels: <6 months, =6 months, and >6 months.
2.3. Maternal factors
Maternal age was classied into 3 groups: 1829, 30
39, and 4049 years old. Maternal working status was also
included as a dichotomous variable (currently working vs.
not) in the model. Maternal education was recoded into
three levels: low (no education), middle (preparatory or
primary) and high (secondary or higher).
Maternal indigenousness was classied as a dichot-
omous variable with a value of 1 assigned if the mother
was indigenous and a value of 0 assigned if the mother
was non-indigenous. Indigenousness was coded as yes
based on the self-identication of mothers as indigenous.
They reported being Mayan (Kiche, Qeqchi, Kaqchikel,
Mam, and other Mayan) and non-Mayan (Garifuna, and
Xinka).
Maternal short stature was dened as a height less than
145 cm, following guidelines in a previous international
report (ACC/SCN, 1992). Other predictive variables
examined for their potential role in SCOM included
information on parity or, the total number of live births
that the mother had, which was used as a continuous
variable.
2.4. Household characteristics
Households in our sample were classied into 2 groups
depending on their area of residence as rural or urban
households. Their main water source was coded into ve
categories: pipes inside the dwelling, pipes within the
property, pipes from a public well, river/lake/stream, and
other. Type of sanitary system was categorized into 3
groups: poor (none), middle (washable toilet/latrine/
covered well), and good (connected to a drainage
system/connected to a septic tank).
As an indicator of household wealth status, we used
the total household consumption (THC), a measure of
economic status previously assessed by the Guatemala
National Institute of Statistics with technical support
from the World Bank (2003). It has been reported that
total household consumption is a better measure of
wealth status than expenditure and income at a house-
hold level (ODonnell et al., 2007). THC was calculated by
converting all household expenditures into the monetary
value of goods, including home-produced foods and
durable goods. Then, the per capita total household
consumption was estimated using THC divided by the
total number of household members. We used per capita
total household consumption instead of per adult
equivalent household consumption. A World Bank report
showed that distribution of per capita household con-
sumption in quintiles and deciles was similar to that of
per adult equivalent household consumption (World
Bank, 2003).
To assess the role of diet in SCOM, we used the
information about food available for family consumption
collected in the LSMS. Food variety score was calculated
as the sum of the total number of 97 food items
available in each household over the previous 15 days
(Hatloy et al., 2000). Then the score was categorized into
tertile groups based on the distribution of the study
population.
Two additional household variables were included in
our analysis: ownership of a vehicle and of a television,
which were both recoded as dichotomous variables.
 J. Lee et al. / Economics and Human Biology 8 (2010) 188196 191

Table 1
Socio-economic, demographic and nutritional statuses by the nutritional types of child-mother pairs (n = 2261).

SCOM SCNM NCOM NCNM

N (%) 405 (18.2) 762 (33.8) 567 (25.2) 527 (22.8)

Child characteristicsa
Age (months, mean  SD) 37.6  13.5 37.5  13.9 38.3  13.7 35.8  14.4
Sex (% male) 44.7 56.4 54.0 56.4

Maternal characteristicsa
Age (years, mean  SD) 30.4  7.3 29.3  7.1 31.0  6.6 28.8  6.7

Working status and occupation

Not working 56.8 66.0 56.5 65.1
Currently working (%) 43.2 34.0 43.5 34.9
Professional/technical work 2.3 1.1 7.9 7.1
Sales/service work 12.6 4.9 17.6 10.9
Agricultural/mechanical work 15.7 13.3 6.2 7.6
Unskilled work/not specied 12.7 14.7 11.9 9.3

Education (%)
Low (no education) 44.0 54.7 23.3 27.0
Middle (preparatory or primary) 46.9 40.5 44.3 47.4
High (secondary or higher) 9.1 4.8 32.4 25.6

Indigenousness (% indigenous) 50.8 62.3 20.6 24.9

Short stature (% maternal height <145 cm) 45.2 44.3 18.9 16.9
Parity (number of live births, mean  SD) 4.7  3.1 4.3  2.7 3.8  2.5 3.3  2.3

Household characteristicsa
Household size (mean  SD) 6.7  2.3 6.5  2.2 6.1  2.2 5.7  2.1
Area of residence (% urban) 30.8 25.4 53.0 47.2
HH consumption, per capita (Q, mean  SD) 4136  3092 3241  2848 7102  5856 7037  7324

Food diversity score (%)b

First tertile 32.0 44.3 19.7 33.5
Second tertile 37.8 37.4 33.4 28.4
Third tertile 30.2 18.2 46.9 38.2

Abbreviations: BMI, body mass index, SCOM, stunted child and overweight mother; SCNM, stunted child and normal weight mother; NCOM, non-stunted
child and overweight mother; NCNM, non-stunted child and normal weight mother; HH, household.
a
The total sum of percentages included in the columns may not be 100% due to rounding.
b
Tertile of food variety score was based on 2261 households, range for tertile (rst: 225, second: 2635, third: 3671).

2.5. Data analysis 3. Results

Data management was performed with the use of SPSS
version 16.0 (SPSS Inc., Chicago, IL) and all analyses
employed the use of Intercooled STATA (version 10.0; Stata
Corporation College station, TX).1
We employed bivariate logistic regressions and multi-
variate logistic regressions for predicting child stunting
and maternal overweight separately. Then, we utilized
logistic models to compare SCOM with NCNM households,
with the later one as the reference group. We also
examined similar models with the other two types of
households (SCNM and NCOM) with the same reference
group.
We estimated crude and adjusted odds ratio (OR) and
95% condence intervals (CI) in our logistic models. To test
our hypotheses, we used two sided p values <0.05 in all
statistical analyses.
1
We used the svyset commands in STATA to adjust for the complex
survey design effects (World Bank, 2003). Sample weights were applied to
our analysis.
We found 405 SCOM pairs (18.2%) out of a total of 2261
households (Table 1). The proportion of maternal short
stature in SCOM households was 45.2%. The proportions of
other nutritional types of child and mother pairs were:
SCNM 33.8%; NCOM 25.2%; and NCNM 22.8%.
About one-third of SCOM households were urban and,
in comparison, close to half of the NCNM pairs were living
in urban areas (Table 1). About half of SCOM families,
relative to one-quarter of NCNM families, had indigenous
mothers. Average per capita total household consumption
in quetzals (Q) was much lower in SCOM than in their
NCNM counterparts (7102 Q). On average, mothers from
the SCOM households had about 5 live births compared to
3 from those in the NCNM households. The proportion of a
high level of maternal education was smaller in SCOM than
in NCNM pairs. Additional details about the characteristics
of the other types of households examined in this study are
also presented in Table 1.
We found that the proportion of stunted children was
73% in households with short mothers compared to 42% in
households with normal-stature mothers (Fig. 1). How-
ever, the proportion of overweight mothers was statisti-
192 J. Lee et al. / Economics and Human Biology 8 (2010) 188196
Fig. 1. Child stunting, maternal overweight by maternal short stature.
cally similar between households with short mothers and
with normal-stature mothers.
SCOM was detected in 26% and 15% of the households
with or without short mothers, respectively (Fig. 2). On the
other hand, NCNM was found in 12% of the households
with short mothers and in 28% of those households with
normal height mothers.
Maternal indigenous status and maternal short stature
were signicantly associated with child stunting (Table 2).
A high level of maternal education signicantly decreased
the risk of child stunting.
From the multivariate logistic regression analysis, we
identied three variables that signicantly increased the
risk of maternal overweight including: being a working
mother, a higher number of live births, and possession of a
television (Table 2). However, indigenous mothers were at
lower risk of overweight compared with non-indigenous
mothers. Compared with the rst tertile group of per capita
Fig. 2. Nutritional types of childmother pairs by maternal short stature.
total household consumption, the second and third tertile
groups were at a signicantly higher risk of maternal
overweight. Additionally, a higher level of maternal
education did not have a signicant positive effect on
maternal nutritional status in Guatemala.
Results from multivariate logistic regression showed
that SCOM pairs were more likely to have short mothers,
higher parity, indigenous mothers, and working mothers,
compared with NCNM pairs (Table 3).
4. Discussion
Consistent with our results, Garret and Ruel demon-
strated that the prevalence of the familial coexistence of
child stunting and maternal overweight increased from
13% to 16% between 1995 and 2000 in Guatemala (Garrett
and Ruel, 2003, 2005). We can expect that concurrence of
child stunting and maternal overweight within the same
households will keep increasing if we do not implement
effective nutrition and socio-economic development pro-
grams to curb this rapidly emerging nutrition problem.
In this study we were able to disentangle some of the
predictors of child stunting, maternal overweight and the
familial coexistence of child undernutrition (stunting) and
maternal overnutrition (overweight), which is a contribu-
tion to the growing body of research that could support the
re-orientation of conventional nutrition and SES interven-
tion programs directed to either one of the extremes of the
malnutrition continuum: child undernutrition or maternal
overweight.
According to our results, socio-economic characteristics
of SCOM households were signicantly different from
those in NCNM households. Further, our ndings indicated
that maternal short stature was signicantly associated
with SCOM. Other research also shows that maternal short
stature was associated with both maternal obesity and
child stunting in the semi-arid region of Alagoas, Brazil
(Ferreira et al., 2009). Additionally, Schroeder et al. (1999)
investigated that severely stunted children had a sig-
nicantly higher risk of developing adult abdominal
fatness. Maternal short stature reects malnutrition in
 J. Lee et al. / Economics and Human Biology 8 (2010) 188196 193

Table 2
Predictors of child stunting and maternal overweight in Guatemala.

Stunting in children Overweight in mothers

Adjusted OR (95% CI) Adjusted OR (95% CI)

Child characteristics
Age (months)
1224 1.00
2536 1.02 (0.73, 1.43)
3748 1.16 (0.82, 1.64)
4960 0.97 (0.66, 1.42)

Sex
Female 1.00
Male 0.88 (0.66, 1.17)

Up-to-date vaccination
No 1.00
Yes 1.07 (0.81, 1.41)

Respiratory illness (last month)

No 1.00
Yes 1.05 (0.81, 1.37)

Diarrhea (last month)

No 1.00
Yes 1.16 (0.88, 1.54)

Duration of exclusive breastfeeding

<6 months 1.00 1.00
=6 months 0.81 (0.57, 1.17) 1.05 (0.75, 1.49)
>6 months 1.17 (0.85. 1.59) 1.20 (0.91, 1.56)

Maternal characteristics
Age (years)
1829 1.00 1.00
3039 0.58 (0.43, 0.78)*** 1.16 (0.90, 1.50)
4049 0.58 (0.31. 1.11) 1.28 (0.79, 2.06)

Occupation
Not working 1.00 1.00
Working 1.33 (1.00. 1.79) 1.32 (1.00, 1.73)*

Education
Low (no education) 1.00 1.00
Middle (preparatory or primary) 0.82 (0.59, 1.12) 1.17 (0.88, 1.56)
High (secondary or higher) 0.49 (0.26, 0.94)* 1.50 (0.93, 2.42)

Indigenousness
Not indigenous 1.00 1.00
Indigenous 2.42 (1.77. 3.30)*** 0.73 (0.56, 0.96)*

Short stature (maternal height <145 cm)

No 1.00 1.00
Yes 2.02 (1.49, 2.74)*** 1.28 (0.98, 1.68)
Parity (number of live births) 1.05 (0.99, 1.11) 1.12 (1.06, 1.18)***

Household characteristics
Area of residence
Rural 1.00 1.00
Urban 1.05 (0.74, 1.49) 0.82 (0.60, 1.11)

Per capita total household consumption

First tertile (< 2600 Q) 1.00 1.00
Second tertile (26004920 Q) 0.68 (0.47, 0.98)* 1.55 (1.11, 2.17)*
Third tertile (> 4920 Q) 0.40 (0.25, 0.66)*** 2.43 (1.46, 4.04)**

Main water source

Pipes inside the dwelling 1.00
Pipes within the property 1.56 (1.03, 2.38)*
Pipes from a public well 1.31 (0.87, 1.96)
River/lake/stream 0.99 (0.60, 1.62)
Other 1.12 (0.65, 1.94)

Type of sanitary system

Poor 1.00
Middle 0.90 (0.60, 1.35)
Good 0.63 (0.36, 1.08)
194 J. Lee et al. / Economics and Human Biology 8 (2010) 188196
Table 2 (Continued )
Food diversity score
First tertile (25)
Second tertile (2635)
Third tertile (36)
Possession of vehicle
No
Yes
Possession of television
No
Yes
Abbreviations: OR, odds ratio; CI, condence interval. Multivariate logistic regression model comparing, in the second column, stunted children (n = 1167)
vs. non-stunted children (n = 1094) and, in the third column, overweight mothers (n = 972) vs. normal weight mothers (n = 1289), using weighted data with
adjustment for the complex design of the study.
*
p < 0.05.
**
p < 0.01.
***
p < 0.001.
early life, and many studies have shown that early
malnutrition changes important metabolic pathways.
Stunted children showed impaired fat oxidation and
greater susceptibility to the consequences of high fat diets
(Sawaya et al., 1998; Hoffman et al., 2000; Sawaya and
Roberts, 2003). This metabolic condition combined with a
higher intake in fat and carbohydrate and a physically
inactive life style can lead to adult obesity with short
stature (Sawaya et al., 2004). Since Guatemalan women
have the lowest mean height (148 cm) among women in
Latin America and the Caribbean, this helps explain why
Guatemala has the highest prevalence of child stunting as
well as concurrence of child stunting and maternal
overweight within the same household (Martorell et al.,
1998).
In addition to maternal short stature, higher parity in
women was also signicantly related to higher prevalence
of the familial coexistence of maternal overweight and
child stunting. Parity shows a positive association with
weight gain due to pregnancy and the onset of obesity in
women (Brown et al., 1992; Wolfe et al., 1997). Accord-
ingly, high fertility rates may provide an explanation for
the higher overweight rate for adult females. Guatemala
has a fertility rate of 5, which is the highest among Latin
American countries (with an average rate of 2.7) and is also
high compared to the average fertility rate of women
worldwide of 2.8 for the period 19952000 (United
Nations, 2001). In Guatemala, indigenous women living
in rural areas were affected the most because of a lack of
knowledge about fertility and contraceptive methods and
limited access to these methods (Center for Reproductive
Rights, 2003). The considerably higher parity of many
indigenous mothers might contribute to the occurrence of
SCOM pairs.
Several studies suggest that low food variety char-
acterized by micronutrient malnutrition could increase the
risk of SCOM pairs. We can infer that this diet is
characterized by high intake of dietary energy and low
intake of micronutrients from a relatively monotonous
diet. Due to their inability to afford high-nutrient-dense
(HND) foods, such as fruits and vegetables, they may
Stunting in children Overweight in mothers
Adjusted OR (95% CI) Adjusted OR (95% CI)
1.00 1.00
1.27 (0.93, 1.75) 1.31 (0.99, 1.72)
1.04 (0.71, 1.53) 1.41 (1.02, 1.97)*
1.00
0.79 (0.54, 1.15)
1.00
1.40 (1.05, 1.87)*
replace these foods with low-nutrient-dense (LND) foods,
such as sweeteners, added fats and baked goods. This
dietary pattern contributes to high energy intakes and
micronutrient deciencies. For example, as consumption
of LND foods increases in adult Americans, intake of foods
from the 5 major food groups (grains, fruits, vegetables,
dairy, and meat and beans) decreases (Kant, 2000). Kant
(2000) argues that a high intake of LND foods is associated
with low serum concentrations of vitamins A, E, C, B-12,
folate, and carotenoids in U.S. adults. Recent studies in
Egypt have also found that micronutrient-decient
mothers are 80% more likely to be overweight or obese
than non-decient mothers (Asfaw, 2007). Additionally, a
low diversity of foods, especially from animal sources,
contributes to micronutrient deciencies, which in turn
could be associated with child stunting. Low food variety
and dietary diversity scores substantially increased the
risk of child stunting in urban areas of Mali (Hatloy et al.,
2000). Furthermore, a low intake of animal foods is
specically associated with short stature in children when
overall dietary diversity is low or the child is not being
breastfed (Marquis et al., 1997). Animal foods are rich food
sources of several micronutrients (especially zinc, iron, and
vitamin A) due to their high bioavailability and high
concentration (Murphy and Allen, 2003; Rivera et al.,
2003). Zinc, iron, and vitamin A are essential nutrients for
linear growth in children (Lawless et al., 1994; Nishi, 1996;
Clausen and Dorup, 1998; Shankar and Prasad, 1998;
Rivera et al., 2003).
This study has several major strengths. First, we used
the LSMS data set from a large nationally representative
sample covering 8 regions and 22 provinces in Guatemala.
Second, we produced reliable estimates of predictors of
SCOM by controlling our statistical models by the complex
design of the survey from where we obtained our study
sample. Third, we used per capita total household
consumption to measure living standards at the household
level. This is important due to the limitations of measuring
household economic status using household income and
expenditure in developing countries. Additionally, house-
hold expenditure does not capture food households
 J. Lee et al. / Economics and Human Biology 8 (2010) 188196 195

Table 3 during pregnancy were not collected in this data set. If, for
Predictors of SCOM (n = 405) compared to NCNM (n = 527) households.
example, there was any major change in household
Adjusted OR (95% CI) conditions or in the diet between the past and time of
Child characteristics the survey, we would miss important predictors regarding
Age (months) the familial coexistence of stunted children and over-
1224 1.00 weight mothers.
2536 0.94 (0.58, 1.53) Another limitation is that we do not know the
3748 1.22 (0.73, 2.02)
distribution of food within a household. If any specic
4960 0.95 (0.54, 1.67)
sex or age group had access to more or higher quality food
Duration of exclusive breastfeeding for any reason, this imbalance could have inuenced child
<6 months 1.00
=6 months 0.92 (0.55, 1.52)
stunting and maternal overweight. However, this study
>6 months 1.61 (1.06, 2.47)* does not take into account inequities in intra-household
food allocation. Additionally, a limitation in the evaluation
Maternal characteristics
Age (years)
of household diet is the expenditure on food and drinks
1829 1.00 consumed outside the household. It is more difcult to
3039 0.58 (0.36, 0.94)* assess the diet of households that spend more money on
4049 0.79 (0.40, 1.54) food consumed outside of the house because we cannot
Currently working determine household dietary diversity from information
Not working 1.00 about outside household food expenditure.
Working 1.67 (1.08, 2.57)*

Indigenousness 5. Conclusion
Not indigenous 1.00
Indigenous 1.98 (1.25, 3.12)** Intervening in dual burden households without know-
Short stature (maternal height <145 cm) ing the common risk factors for SCOM pairs is complicated.
No 1.00 By targeting interventions aimed at only one type of
Yes 3.12 (2.08, 4.69)***
malnutrition in the child and mother pair, we could benet
Parity 1.20 (1.09, 1.31)***
one individual and harm the other (Doak et al., 2005). For
Household characteristics example, if emphasis is placed on reducing food con-
Area of residence
sumption, targeting only obese adults without considering
Rural 1.00
Urban 0.63 (0.37, 1.07) the possibility that their stunted children may, in fact, need
more food, the poor nutritional status of the child may
Per capita total household consumption
remain unchanged or may worsen. Furthermore, those
First tertile (<2600 Q) 1.00
Second tertile (26004920 Q) 1.09 (0.65, 1.83) targeted interventions that provide additional food may
Third tertile (> 4920 Q) 1.01 (0.50, 2.04) not enhance family nutrition or improve its economic
capacity. If a household is provided good-quality food in
Food diversity score
First tertile (25) 1.00 sufcient quantities but it is not distributed among
Second tertile (2635) 1.71 (1.06, 2.74)* household members based on the individuals needs, it
Third tertile (36) 1.71 (0.97, 3.03) may not improve results. Examining the key risk factors of
Abbreviations: SCOM, stunted child and overweight mother; NCNM, non- stunted children and overweight mothers at both the
stunted child and normal weight mother. Multivariate logistic regression household and individual level is a critically important rst
models, for with weighted data and adjusted by the complex design of the step in developing comprehensive nutrition and socio-
sampling technique. Other variables included in the model, but not
economic intervention programs for these population
statistically signicant included, for children: sex, vaccination status and
presence of disease, education of the mother and, from the household: groups. The challenge for the decision makers and service
main water source, type of sanitary system, and possession of vehicle and deliverers is to guide SCOM households to deal equally
of television. with both extremes of the malnutrition continuum, with a
*
p < 0.05. life cycle approach.
**
p < 0.01.
***
p < 0.001.
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