undernutrition and Gender

Hello Tammam,

interesting question! There may be (at least) two ways looking at it: from the point of view of a greater vulnerability, as you suggest, but also from the point of view of OTP access. You are right that most current evidence is leaning towards a greater vulnerability of boys, although in the past that was reverse. However, these trends are often very context-dependent so it might be difficult to give you a straightforward answer. In both cases, though, you may need to look at socio-cultural practices related to breastfeeding, IYCF, hygiene, access to health centers, etc. to understand what may be causing a described phenomenon. It could be a question of different hygiene practices, which can expose boys and girls to pathogens differently, while repetitive infections could lead to malnutrition; it could be that boys have higher access to nutritious foods or they are preferred for medical treatment when they fall ill. If girls are not and their treatment for common morbidities is delayed, they may be more vulnerable to malnutrition as a consequence. In some extreme contexts, OTP may also be perceived as a coping strategy for the entire household and in those cases, a child's caregiver might attempt to induce diarrhoea, and malnutrition as a consequence, to have access to OTP support (likely in contexts where RUTF is considered as "food"). Those are just random thoughts that came to mind, not knowing what specific context you are referring to.

Happy to chat more if helpful.

Lenka

Hi,

What is the admission criteria/screening processes for your program (MUAC only?), as there has been some evidence showing greater sensitivity of MUAC for girls which could be another explanation for your observation. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6024773/#:~:text=The%20gender%20bias%20of%20MUAC,acute%20malnutrition%20than%20MUAC%20alone.

I have the impression this may be partly explained by differences in upper arm fat deposits, but someone with more expertise than I can hopefully comment on the reason for the sex differences. https://www.tandfonline.com/doi/abs/10.1080/03014469200001882

Hello there Tammam

Thanks so much for your question.  I hope I can offer some ideas. 

I have been studying sex differences in undernutrition and have just published a paper (https://gh.bmj.com/content/5/12/e004030) which shows that boys are more likely to be wasted, stunted and underweight than girls.  This seems to reflect a greater biological vulnerability as has been documented in neontal, infant health and evolutionary biology fields. However, it is worth noting that we did find some contextual exceptions whereby more girls are affected (possibly explained by over-riding social factors) and perhaps this would explain your findings.  Where are you based?  

We are currently exploring some of the reasons for these differences and sadly there is no simple explanation as to why there may be more boys or more girls in a given context.  In trying to break down the possible sources of these differences, we are exploring factors such as maternal health and nutrition and fetal environments, birthweight, environment and epi-genetics, immune and endocrine differences, caring and feeding practices, health seeking practices, and gender preferences, all of which have the potential to affect nutritional status differently in boys and girls. 

Given you highlight that your findings are not reflective of national population patterns, perhaps there are a few questions to consider.  Are your findings the same for all age groups? Is gender preference a feature of the surrounding community? Could it be a matter of survivor bias, whereby boys are not reaching the OTP (historical famine literature would support this if relevant to context)?  Finally, are there any underlying health conditions that might affect boys morbidity/mortality more than girls and prevent attendance?

I hope this is of some help, please do feel free to get in touch if I can help further

Very best

Susan

It is interesting question. Looking at the admission data of multiple years, more girls admitted. However, Looking at all population surveys, malnutrition is higher in Boys than Girls.

Some of the reasons why more gilrs are admitted than boys could be due to biasness of MUAC towards grls. The second reason could be attendance rate. In rural context, usually boys can go to fields. This can can be confirm by looking at screening data. i did look at some data and confirm that less number of boys are screened than girls.

With regards to popluation surveys findings,  why boys malnourished than girls, one reason could be due the fact that boys are more active who can burn more calori. Moreover, as boys are active, they can go around and interact with environment that can expose them for various untended result. the other reason could be clothe during weight measurment where girls more likely wear heavy clothe. it is culturally difficult to request for girls to be naked.   

The other method to check the difference whether it is started from conception is cheking birth weight of  both boys and grils. 

Thanks all

The responses have been very helpful to me as this is one of the questions we try to answer....

thank you very much for your responses. it encouraged me to look deeply into literature review and came up with these:

- All SMART surveys (Chai Square) showed boys/girls ratio  is >2; boys are more affected by malnutrition than girls and this is aligned with global standards. In contrast to this: girls are more admitted than boys during nturition programming. Weight/Height Z-score chart was the reason behind this as SMART survey data used to be processed by ENA which is using WHO  weight/height Z-score (segregated to boys and girls) and the Z-score chart being used at health facilites for programming is the usual chart (both boys and girls are in one chart); difference around 200 gm between the two charts.

Why boys are more affected than girls:

I have read Susan Thurstans et al article's conclusion that boys are more likely to be affected by undernutrition than girls, again this aligns with global standards/SMART survyes findings. However Johan G. Eriksson et al in their article "Boys live dangerously in the womb" stated that it might be attributed to Placental growth theory where boys' plancental weight is bigger and more efficient than female placental weight but have less reserve capacity than girls placenta. Another argument by them is that boys are growing faster and more responsive to maternal nutrients  than girls and that could be putting them at risk of undernutrition as a response to low maternal nutrition or needs for their faster growth.

Best  

Different reasons were raised on this issue by prior studies. A meta-analysis of 16 demographic and health surveys reported that male children in sub-Saharan Africa were more likely to be malnourished compared to females in the same age group, but the pattern was not consistent in all studies. The same study reported that sex differences in malnutrition were more pronounced in the lowest SES groups. Indirectly it reaffirms that stunting, a proxy for child health inequalities, as well as a proxy for socio-economic inequalities. (Wamani et al., 2007). But it needs further study.