Document Type


Department or Administrative Unit

Nutrition Exercise and Health Sciences

Publication Date



Objectives The aim of this study is to fill a key information gap on the nutrition-related epidemiology of orphaned and vulnerable children living within institution-based care (IBC) across six countries.

Design A retrospective analysis with Shewhart control charts and funnel plots to explore intersite and over time variations in nutritional status.

Setting We conducted a retrospective analysis of records from Holt International’s Child Nutrition Programme from 35 sites in six countries; Mongolia, India, Ethiopia, Vietnam, China and the Philippines.

Participants Deidentified health records from Holt International’s online nutrition screening database included records from 2926 children, 0–18 years old. Data were collected from 2013 to 2020 and included demographic and health information.

Results At initial screening, 717 (28.7%) children were anaemic, 788 (34.1%) underweight, 1048 (37.3%) stunted, 212 (12.6%) wasted, 135 (12%) overweight or obese and 339 (31%) had small head circumference. Many had underlying conditions: low birth weight, 514 (57.5%); prematurity, 294 (42.2%) and disabilities, 739 (25.3%). Children with disabilities had higher prevalence of malnutrition compared with counterparts without disabilities at baseline and 1-year screenings. There was marked intersite variation. Funnel plots highlight sites with malnutrition prevalence outside expected limits for this specific population taking into consideration natural variation at baseline and at 1 year. Control charts show changes in site mean z-scores over time in relation to site control limits.

Conclusions Malnutrition is prevalent among children living within IBC, notably different forms of undernutrition (stunting, underweight, wasting). Underlying risk factors are also common: prematurity, low birth weight and disability. Nutrition interventions should take into account the needs of this vulnerable population, especially for infants and those with disabilities. Using control charts to present data could be especially useful to programme managers as sites outside control limits could represent: problems to be investigated; good practices to be shared.


This article was originally published Open Access in BMJ Open. The full-text article from the publisher can be found here.


BMJ Open

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Creative Commons Attribution-NonCommercial 4.0 International License
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License


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