The relationship between stunting and underweight of infants with altitude in Tibet-based on propensity score matching method
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摘要:
目的 西藏自治区(简称西藏)儿童生长发育状况整体不佳，其与中国和WHO的标准相比都有较大差距，本研究基于“西藏0~5岁儿童营养与健康调查”分析西藏婴幼儿生长迟缓和低体重发生率及其与海拔的关系。 方法 采用分层、多阶段与规模大小成比例的抽样和整群抽样相结合的抽样方法，抽取0~3岁婴幼儿进行现场体格检查并对其监护人进行问卷调查，采用倾向性评分匹配的方法以均衡两个比较组之间的混杂因素。单因素logistic回归分析模型分析海拔与生长迟缓和低体重的关系。 结果 西藏婴幼儿生长迟缓和低体重率分别为20.9%和8.7%。进行1∶1倾向性评分匹配后分别获得324对，共计648例匹配的样本，各混杂因素在比较组间达到均衡。匹配后，相对于居住较低海拔(＜4 000 m)的婴幼儿，居住高海拔(≥4 000 m)的婴幼儿生长迟缓和低体重风险的OR(95% CI)值分别为2.31(1.74~3.10)和1.95(1.27~3.09)。无论男女、家庭收入水平、是否为低出生体重，高海拔都会增加生长迟缓风险，而对低体重的影响只在男性、家庭收入水平较高、出生体重正常和足月生产的婴幼儿中的差异有统计学意义(均有P＜0.05)。 结论 西藏婴幼儿生长发育水平低，居住高海拔对生长迟缓有较大影响。 Abstract:Objective To investigate the incidence of stunting and underweight of infants in Tibet and its relationship with altitude. Methods Multi-stage stratified cluster sampling method was used to select infants aged 0-3 years for on-site physical examination and questionnaire survey of guardians. The propensity score matching method was used to balance the confounding factors between the two comparison groups. Univariate logistic regression was used to analyze the relationship between altitude with stunting and underweight. Results The incidence of stunting and underweight of infants in Tibet were 20.9% and 8.7%. After conducting 1∶1 propensity score matching method, 324 pair, 648 matched samples were obtained. The confounding factors were balanced between the comparison groups. After matching, compared with infants living at relative low altitude (< 4 000 meters), the OR and 95% CI of stunting and underweight of infants living at high altitude (≥4 000 meters) were 2.31(1.74-3.10) and 1.95(1.27-3.09), respectively. High altitude increased the risk of stunting regardless of gender, family income level and birth weight. while increased the risk of underweight in boy, infants with high family income level, normal birthweight and term production (all P < 0.05). Conclusions The growth and development of infants in Tibet is poor. Living at high altitude has a great impact on growth and development of infants. -
Key words:
- Infants and young children /
- Stunting /
- Underweight /
- Altitude /
- Tibet
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表 1 匹配前高海拔与较低海拔组婴幼儿基本情况的比较[n(%)]
Table 1. Comparison of the characteristics of infants in high and relative low altitude before matching [n(%)]
基本特征 合计(N=1 429) 较低海拔组(n=836) 高海拔组(n=593) χ2值 P值 性别 0.010 0.524 男 746(52.2) 430(51.4) 316(53.3) 女 683(47.8) 406(48.6) 277(46.7) 月龄段(月) 3.353 0.022 0~＜6 241(16.9) 121(14.5) 120(20.2) 6~＜12 258(18.1) 145(17.3) 113(19.1) 12~＜18 277(19.4) 163(19.5) 114(19.2) 18~＜24 256(17.9) 158(18.9) 98(16.5) 24~36 397(27.8) 249(29.8) 148(25.0) 家庭年均收入(元) 0.804 ＜0.001 ＜12 000 258(18.1) 104(12.4) 154(26.0) 12 000~＜20 000 744(52.1) 522(62.4) 222(37.4) ≥20 000 427(29.9) 210(25.1) 217(36.6) 母亲文化程度 6.789 ＜0.001 小学及以下 1 154(80.7) 709(84.8) 445(75.0) 初/高中 197(13.8) 83(9.9) 114(19.2) 大专及以上 78(5.5) 44(5.3) 34(5.8) 父亲文化程度 10.067 0.002 小学及以下 1 114(78.0) 679(81.2) 435(73.4) 初/高中 251(17.6) 122(14.6) 129(21.8) 大专及以上 64(4.4) 35(4.2) 29(4.9) 辅食添加时间 22.924 ＜0.001 未添加/不清 169(11.8) 34(4.1) 135(22.8) 过早 458(32.1) 263(31.5) 195(32.9) 正常 541(37.9) 424(50.7) 117(19.7) 过晚 261(18.3) 115(13.8) 146(24.6) 贫血 15.555 ＜0.001 否/不清楚 1 412(98.8) 834(99.8) 578(97.5) 是 17(1.2) 2(0.2) 15(2.5) 喂养方式 19.480 < 0.001 基本/纯母乳 868(60.7) 564(67.5) 304(51.3) 混合 423(29.6) 175(20.9) 248(41.8) 人工 138(9.7) 97(11.6) 41(6.9) 足月生产 3.545 0.499 否 51(3.6) 27(3.2) 24(4.0) 是 1 378(96.4) 809(96.8) 569(96.0) 喂过母乳 2.651 ＜0.001 否 133(9.3) 50(6.0) 83(14.0) 是 1 296(90.7) 786(94.0) 510(86.0) 睡眠充足 4.541 ＜0.001 否 594(41.6) 192(23.0) 402(67.8) 是 835(58.4) 644(77.0) 191(32.2) 低出生体重 25.404 0.215 否 1 331(93.1) 785(93.9) 546(92.1) 是 98(6.9) 51(6.1) 47(7.9) 出生身长(x±s, cm) 49.09±2.2 49.2±2.3 48.9±2.0 17.402 a 0.004 生长迟缓 67.866 ＜0.001 否 1 131(79.1) 724(86.6) 407(68.6) 是 298(20.9) 112(13.4) 186(31.4) 低体重 7.693 0.007 否 1 305(91.3) 778(93.1) 527(88.9) 是 124(8.7) 58(6.9) 66(11.1) 注：a两独立样本t检验的F统计量。 
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表 2 匹配后高海拔与较低海拔组婴幼儿基本情况的比较[n(%)]
Table 2. Comparison of the characteristics of infants in high and relative low altitude after matching [n(%)]
基本特征 较低海拔组(n=324) 高海拔组(n=324) χ2值 P值 性别 0.500 0.530 男 159(49.1) 168(51.9) 女 165(50.9) 156(48.1) 月龄段(月) 0.925 0.921 0~＜6 56(17.3) 59(18.2) 6~＜12 60(18.5) 67(20.7) 12~＜18 61(18.8) 60(18.5) 18~＜24 53(16.4) 53(16.4) 24~36 94(29.0) 85(26.2) 家庭年均收入(元) 1.664 0.435 ＜12 000 63(19.4) 75(23.1) 12 000~＜20 000 139(42.9) 139(42.9) ≥20 000 122(37.7) 110(34.0) 母亲文化程度 0.518 0.772 小学及以下 257(79.3) 258(79.6) 初/高中 46(14.2) 49(15.1) 大专及以上 21(6.5) 17(5.2) 父亲文化程度 2.084 0.353 小学及以下 243(75.0) 258(79.6) 初/高中 62(19.1) 52(16.0) 大专及以上 19(5.9) 14(4.3) 辅食添加时间 1.604 0.659 未添加/不清 34(10.5) 40(12.3) 过早 101(31.2) 110(34.0) 正常 113(34.9) 101(31.2) 过晚 76(23.5) 73(22.5) 贫血 0.202 1.000 否/不清 322(99.4) 321(99.1) 是 2(0.6) 3(0.9) 喂养方式 2.668 0.263 基本/纯母乳 205(63.3) 190(58.6) 混合 109(33.6) 117(36.1) 人工 10(3.1) 17(5.2) 足月生产 0.000 1.000 否 11(3.4) 11(3.4) 是 313(96.6) 313(96.6) 喂过母乳 0.063 0.901 否 37(11.4) 35(10.8) 是 287(88.6) 289(89.2) 睡眠充足 0.099 0.813 否 156(48.1) 152(46.9) 是 168(51.9) 172(53.1) 低出生体重 0.021 1.000 否 298(92.0) 299(92.3) 是 26(8.0) 25(7.7) 出生身长(x±s, cm) 48.9±2.5 49.0±2.0 26.011 a 0.498 注：a两个独立样本t检验的F统计量。
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表 3 匹配后海拔与生长迟缓和低体重风险的logistic回归分析模型
Table 3. Logistic regression between altitude and the risk of stunting and underweight after matching
海拔(m) 生长迟缓 低体重 OR(95% CI)值 P值 OR(95% CI)值 P值 ＜4 000 1.00 1.00 ≥4 000 2.31(1.74~3.10) ＜0.001 1.95(1.27~3.09) 0.003
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表 4 匹配后海拔与生长迟缓和低体重风险的分层分析
Table 4. Stratified analysis of altitude and risk of stunting and underweight after matching
亚组 合计 生长迟缓 低体重 OR(95% CI)值 P值 OR(95% CI)值 P值 性别 男 326 1.99(1.35~2.98) ＜0.001 2.40(1.28~4.96) 0.010 女 320 2.72(1.79~4.23) ＜0.001 1.62(0.90~3.04) 0.110 家庭年均收入(元) ＜12 000 137 2.64(1.37~5.59) 0.006 2.49(0.91~9.67) 0.110 12 000~＜20 000 277 2.14(1.44~3.22) ＜0.001 1.56(0.87~2.94) 0.150 ≥20 000 232 2.49(1.47~4.46) 0.007 2.48(1.15~6.21) 0.030 喂养方式 基本/纯母乳 394 2.37(1.64~3.50) ＜0.001 2.63(1.34~5.85) 0.008 混合 225 2.30(1.46~3.76) ＜0.001 1.49(0.82~2.82) 0.200 人工 27 1.59(0.33~14.15) 0.594 1.59(0.33~14.15) 0.594 低出生体重 否 596 2.27(1.67~3.13) ＜0.001 2.02(1.24~3.45) 0.007 是 50 3.12(1.36~7.70) 0.010 1.96(0.77~5.47) 0.170 是否足月生产 否 20 2.55(0.69~11.82) 0.181 2.55(0.52~23.00) 0.290 是 626 2.30(1.72~3.12) ＜0.001 1.92(1.23~3.10) 0.005
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[1] 丁心悦. 2013年中国2岁以下婴幼儿生长发育状况及其与喂养行为关系的研究[D]. 北京: 中国疾病预防控制中心, 2018.Ding XY. The association between feeding behavior and growth and development of infants under 2 years old in China in 2013[D]. Beijing: Chinese Center for Disease Control and Prevention, 2018. [2] 康轶君, 颜虹, 李强, 等. 2010年拉萨市农村0~35月龄藏族儿童生长发育及营养不良状况[J]. 中华预防医学杂志, 2012, 46(10): 932-936. DOI: 10.3760/cma.j.issn.02530624.2012.10.015.Kang YJ, Yan H, Li Q, et al. Analysis on growth and malnutrition status of Tibetan children aged 0 to 35 months in rural Lhasa in 2010[J]. Chin J Prev Med, 2012, 46(10): 932-936. DOI: 10.3760/cma.j.issn.02530624.2012.10.015. [3] 王宏运, 刘宁, 胡耀文, 等. 高原低氧环境对人体生长发育和营养状况的影响[J]. 西北国防医学杂志, 2008, 29(4): 289-291. DOI: 10.16021/j.cnki.1007-8622.2008.04.042.Wang HY, Liu N, Hu YW, et al. Growth and development of human body and nutrition status in the environment of plateau and hypoxia[J]. Med J NDFNC, 2008, 29(4): 289-291. DOI: 10.16021/j.cnki.1007-8622.2008.04.042. [4] Mohammed SH, Habtewold TD, Abdi DD, et al. The relationship between residential altitude and stunting: evidence from >26 000 children living in highlands and lowlands of Ethiopia[J]. Br J Nutr, 2020, 123(8): 934-941. DOI: 10.1017/S0007114519003453. [5] 李辉, 朱宗涵, 张德英. 2005年中国九市七岁以下儿童体格发育调查[J]. 中华儿科杂志, 2007, 45(8): 609-614. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHEK200708015.htmLi H, Zhu ZH, Zhang DY. A national survey on growth of children under 7 years of age in nine cities of China, 2005[J]. Chin J Pediatr, 2007, 45(8): 609-614. https://www.cnki.com.cn/Article/CJFDTOTAL-ZHEK200708015.htm [6] 黄丽红, 陈峰. 倾向性评分方法及其应用[J]. 中华预防医学杂志, 2019, 53(7): 752-756. DOI: 10.3760/cma.j.issn.0253-9624.2019.07.017.Huang LH, Chen F. The propensity score method and its application[J]. Chin J Prev Med, 2019, 53(7): 752-755. DOI: 10.3760/cma.j.issn.0253-9624.2019.07.017. [7] Liu J, Sun J, Huang J, et al. Prevalence of Malnutrition and Associated Factors of Stunting among 6-23-Month-Old Infants in Central Rural China in 2019. [J]. Int J Environ Res Public Health, 2021, 18(15): 8165. DOI: 10.3390/ijerph18158165. [8] Dang S, Yan H, Yamamoto S. High altitude and early childhood growth retardation: new evidence from Tibet[J]. Eur J Clin Nutr, 2008, 62(3): 342-348. DOI: 10.1038/sj.ejcn.1602711. [9] Ma J, Zhang Z, Niu W, et al. Education, altitude, and humidity can interactively explain spatial discrepancy and predict short stature in 213, 795 Chinese school children[J]. Front Pediatr, 2019, 7(7): 425. DOI: 10.3398/fped.2019.00425. [10] Martínez JI, Román EM, Alfaro EL, et al. Geographic altitude and prevalence of underweight, stunting and wasting in newborns with the INTERGROWTH-21st standard[J]. J Pediatr (Rio J), 2019, 95(3): 366-373. DOI: 10.1016/j.jped.2018.03.007. [11] Weitz CA, Garruto RM, Chin CT, et al. Morphological growth and thorax dimensions among Tibetan compared to Han children, adolescents and young adults born and raised at high altitude[J]. Ann Hum Biol, 2004, 31(3): 292-310. DOI: 10.1080/0301446042000196316. [12] Dittmar M. Linear growth in weight, stature, sitting height and leg length, and body proportions of Aymara school-children living in an hypoxic environment at high altitude in Chile[J]. Z Morphol Anthropol, 1997, 81(3): 333-344. doi: 10.1127/zma/81/1997/333 [13] Leonard WR, Dewalt KM, Stansbury JP, et al. Influence of dietary quality on the growth of highland and coastal Ecuadorian children[J]. Am J Hum Biol, 2000, 12(6): 825-837. DOI:10.1002/1520-6300(200011/12)12:6<825::Aid-ajhb10>3.3.Co;2-5. [14] 徐小红, 边巴卓玛, 王建东, 等. 西藏高海拔地区孕产期保健现状及母婴预后[J]. 中国实用妇科与产科杂志, 2018, 34(11): 1271-1276. DOI: 10.19538/j.fk2018110120.Xu XH, Bianba ZM, Wang JD, et al. Analysis of maternal health status during pregnancy and after delivery and the maternal and neonatal prognosis in high-altitude areas of Tibet[J]. Chin J Pract Gynecol Obstetr, 2018, 34(11): 1271-1276. DOI: 10.19538/j.fk2018110120. [15] Määttä J, Sissala N, Dimova EY, et al. Hypoxia causes reductions in birth weight by altering maternal glucose and lipid metabolism[J]. Scientific Reports, 2010, 10(1): 4260. DOI: 10.1038/s41598-020-61220-x. [16] Grant ID, Giussani DA, Aiken CE. Fetal growth and spontaneous preterm birth in high-altitude pregnancy: a systematic review, meta-analysis, and meta-regression[J]. Int J Gynaecol Obstet, 2022, 157(2): 221-229. DOI: 10.1002/ijgo.13779. [17] 李亚杰, 次仁旺拉, 索朗旺堆, 等. 高原地区0~5岁藏族儿童低出生体重及巨大儿与生长迟缓的关联[J]. 卫生研究, 2022, 51(2): 227-232. DOI: 10.19813/j.cnki.weishengyanjiu.2022.02.009.Li YJ, Ciren WL, Suolang WD, et al. Association of low birth weight and macrosomia with stunting in Tibetan children aged 0-5 years in a plateau area[J]. J Hygiene Res, 2022, 51(2): 227-232. DOI: 10.19813/j.cnki.weishengyanjiu.2022.02.009. [18] Frisancho AR, Baker PT. Altitude and growth: a study of the patterns of physical growth of a high altitude Peruvian Quechua population[J]. Am J Phys Anthropol, 1970, 32(2): 279-292. DOI: 10.1002/ajpa.1330320217. [19] 胡劼, 李华, 牛铭, 等. 高原环境中妊娠期母体缺氧与胎羊先天性心脏病理损伤相关性分析的实验研究[J]. 中国超声医学杂志, 2016, 32(11): 1041-1044. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGCY201611031.htmHu J, Li H, Niu M, et al. Correlation analysis of sheep fetal cariac pathologicl injury with hypoxia environment induration of pregnance: experimental study[J]. Chin J Ultrasound in Med, 2016, 32(11): 1041-1044. https://www.cnki.com.cn/Article/CJFDTOTAL-ZGCY201611031.htm [20] de Meer K, Heymans HS, Zijlstra WG. Physical adaptation of children to life at high altitude[J]. Eur J Pediatr, 1995, 154(4): 263-272. doi: 10.1007/BF01957359 [21] Larson-Nath C, Goday P. Malnutrition in children with chronic disease[J]. Nutr Clin Pract, 2019, 34(3): 349-358. DOI: 10.1002/ncp.10274. -
