1. Socioeconomic disparities in the double burden of child malnutrition in Thailand: Analysis from the Kanchanaburi Demographic Surveillance System Rebecca Firestone and Sureeporn Punpuing Harvard School of Public Health and Mahidol University Children in Thailand face a nutritional paradox. Many segments of the child population continue to be undernourished, while child obesity is becoming more prevalent. Little attention has been given to the mechanisms that drive this paradox. The increasing prevalence of overweight and obesity in many developing countries along with the persistence of undernutrition provides evidence for a double burden of malnutrition. Measures of socioeconomic status can be used to identify who within a population is likely to be vulnerable to overweight or undernutrition. The positive association between SES and obesity in developing countries forms the basis for the notion that obesity and its complications are “disease of affluence”. Consistent evidence indicates that children of less privileged socioeconomic groups are more likely to experience short stature, underweight, and other nutritional deficiencies. The literature on child nutritional risks in low and middle income countries also points to disparities by area of residence, but it is unclear how much these disparities are due to characteristics of rural and urban areas and how much they are attributable to socioeconomic differences of the people within these areas. Aims Aim 1: Establish the magnitude of socioeconomic gradients in child under- and overnutrition among children ages 2-9 in Thailand Aim 2: Determine whether socioeconomic disparities persist after accounting for area of residence Data: Kanchanaburi Demographic Surveillance System (KDSS) 4,610 children ages 2-9, resident in 100 study communities in 2004 Exclusion criteria: biologically implausible values of outcomes; children with missing outcome data; children with non-residential mothers Outcomes: Short stature (height-for-age z-score 95th percentile). All measures based on 2000 CDC reference growth curves Predictors: Household wealth – 16-indicator asset index constructed with principal components analysis; based on all households in KDSS (n=12439); asset scores coded into quintiles, Q1=poorest, Q5=wealthiest Area of residence – urban/rural/upland based on child’s community of residence Analysis: Multivariable logistic regression accounting for multi-stage stratified sampling design Undernutrition Household wealth was inversely associated with odds of short stature and underweight, after accounting for area of residence and socio-demographic factors Short stature also associated with larger household size and being an ethnic minority, two important risk factors for poverty in Thailand Overweight Household wealth was positively associated with odds of overweight, after accounting for area of residence and socio- demographic factors Urban residence remained a risk factor for overweight in multivariable models There are several limitations to our analysis: KDSS protocol had limitations in the collection of precise anthropometric data. Measurement error in the outcomes may have limited the reliability of estimates. Our measure of household wealth assessed relative wealth within the province, and we are not able to associate the measure with an assessment of absolute poverty. We are unable to assess casual relationships in this analysis and lacked data on birthweight, breastfeeding, dietary intake, or physical activity that could illuminate causal mechanisms Unresolved child health inequalities have implications for long term human capital formation Undernutrition, particularly short stature, remains a public health problem in Thailand Concentration of overweight in urban areas suggests obesity epidemic in its early stages – What other aspects of urban environment put children at risk? Challenge to health system to design interventions for undernutrition as well as overweight – Targeting of approaches needed Better documentation of secular trends in child growth and weight status needed Exploration of causes of diverging patterns of nutrition transition Acknowledgement: “The data upon which this analysis is based were collected by the Institute for Population and Social Research, Mahidol University as part of the Kanchanaburi Demographic Surveillance System, which is funded primarily by the Wellcome Trust, United Kingdom”. Contact: Rebecca Firestone (rfiresto@hsph.harvard.edu)rfiresto@hsph.harvard.edu Prevalence of short stature, underweight, and overweight by area of residence among children in Kanchanaburi (n=4610) Odds ratios of undernutrition and overweight, accounting for household wealth and area of residence in Kanchanaburi Provincial distribution of KDSS study communities by area of residence Background Data and Methods Prevalence of short stature, underweight, and overweight by household wealth among children in Kanchanaburi (n=4610) Key findings Limitations Conclusions Urban Rural Upland Myanmar Central Thailand