International Journal of

Environmental Research
and Public Health

Article
Prevalence of Malnutrition and Associated Factors of Stunting
among 6–23-Month-Old Infants in Central Rural China in 2019
Jing Liu , Jing Sun, Jian Huang and Junsheng Huo *

Key Laboratory of Trace Element Nutrition of National Health Commission (NHC), National Institute for
Nutri-tion and Health, Chinese Center for Disease Control and Prevention, No. 27 Nanwei Road,
Xicheng District, Beijing 100050, China; [email protected] (J.L.); [email protected] (J.S.);
[email protected] (J.H.)
* Correspondence: [email protected]

Abstract: This study aimed to evaluate the prevalence of malnutrition and to investigate the associ-
ated factors of stunting among 6–23-month-old infants in poor rural areas of central China. The China
Nutrition Improvement Project on Children in Poor Areas was conducted in 56 national-level poor
counties of seven provinces in 2019. We performed a multivariate binary logistic regression analysis
to determine the associated factors of stunting. This cross-sectional study included 17,193 infants.
The overall prevalence of stunting was the highest (3.9%), followed by overweight (3.0%), under-
weight (2.1%), wasting (2.0%), and obesity (0.5%). Girls [OR = 0.55, 95% CI (0.46, 0.65)], infants
meeting requirements of minimum diversity diet [OR = 0.81, 95% CI (0.67, 0.98)], and mothers with
middle-school or high-school education and above decreased the prevalence of stunting. Infants



with diarrhea in two weeks [OR = 1.26,95% CI (0.98, 1.62)] were at higher odds of stunting. The

 malnutrition status in the study areas was improved, and vulnerable infants were found to need
Citation: Liu, J.; Sun, J.; Huang, J.; additional and earlier monitoring to detect and fundamentally prevent undernutrition.
Huo, J. Prevalence of Malnutrition
and Associated Factors of Stunting Keywords: malnutrition; wasting; stunting; underweight; 6–23-month-old infants; cross-sectional survey
among 6–23-Month-Old Infants in
Central Rural China in 2019. Int. J.
Environ. Res. Public Health 2021, 18,
8165. https://doi.org/10.3390/ 1. Introduction
ijerph18158165
Malnutrition has been defined as a pathological state, including undernutrition and
overnutrition [1]. Infants are the most vulnerable population when it comes to malnutrition.
Academic Editor: Colin W. Binns
Globally, 144.0 million, 47.0 million, and 38 million children under 5 years old suffered
from stunting, wasting, and overweight in 2019, respectively [2]. In China, the overall
Received: 11 June 2021
Accepted: 26 July 2021
prevalence of stunting, underweight, and wasting of 0–5-year-old children was 8.1%, 2.4%,
Published: 2 August 2021
and 1.9%, respectively, in 2013, which represented a decline compared to the prevalence of
the same in 2002 and a more considerable reduction in rural areas than in urban areas [3].
Publisher’s Note: MDPI stays neutral
In rural areas, the prevalence of malnutrition was higher than that in the whole of China.
with regard to jurisdictional claims in
The total prevalence of malnutrition, stunting, and overweight was 19.2%, 8.4%, and
published maps and institutional affil- 8.8%, respectively, among 0–5-year-old infants and children in China’s poor rural areas in
iations. 2016 [4].
Around the world, malnutrition of infants and children continues to be the leading
public health problem in low- and middle-income countries [4–6]. Undernutrition of infants
has been associated with lower human capital, high glucose concentrations, blood pressure,
Copyright: © 2021 by the authors.
and harmful lipid profiles [7]. Based on a study in Lancet, stunting was found to be a key
Licensee MDPI, Basel, Switzerland.
risk factor that requires urgent intervention [8]. Height-for-age (HAZ) for 0–2-year-olds
This article is an open access article
infants was the best predictor of human capital, and stunting of infants was associated
distributed under the terms and with a higher rate of overweight and chronic diseases, including diabetes, cardiovascular
conditions of the Creative Commons disease, breast and other cancers, and mental health issues in later life [9,10]. Some studies
Attribution (CC BY) license (https:// have reported that early childhood stunting is related to greater central adiposity for
creativecommons.org/licenses/by/ adults, including triceps skinfold and waist-to-hip ratio after adjusting for overall fatness
4.0/). and confounders [11,12]. In the last few decades, there has been significant progress in

Int. J. Environ. Res. Public Health 2021, 18, 8165. https://doi.org/10.3390/ijerph18158165 https://www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2021, 18, 8165 2 of 9

improving nutritional status in poor rural areas. However, there has been no timely report
focus on the prevalence of malnutrition in poor rural areas.
Previous studies described the malnutrition status of a large sample size among
children under five years old throughout China. However, there are few data regarding
the prevalence of malnutrition among 6–23-month-old infants in poor rural areas. Our
study firstly used the Child Growth Standard of the WHO to assess the prevalence of
malnutrition among 6–23-month-old infants in 2019 [13]. We used a large sample from
poor rural areas in central China (PRC). The primary aim was to determine the current
prevalence of malnutrition among 6–23-month-old infants in PRC. Additionally, due to the
high prevalence of stunting, we also investigated its associated factors.

2. Materials and Methods

2.1. Study Population
Our data were from the Nutrition Improvement Project on Children in Poor Areas of
China (NIPCPAC) in 2019. The NIPCPAC is a nationally representative survey that used
multiple sampling methods to select eligible 6–23-month-old infants in poor rural areas
of China. The multiple sampling methods included province stratification, multi-stage
sampling, PPS sampling, and systematic random sampling. A total of 45,221 infants were
sampled out of 19 provinces, and 6–23-month-old infants were selected. Our research
included seven provinces, including Hunan, Hubei, Henan, Hebei, Anhui, Jiangxi, and
Shanxi. There were 18,022 participants in our research, and data for 17,193 participants
were analyzed after data cleaning.
The study was approved by the Ethical Committee of the National Institute for
Nutrition and Health in the Chinese Center for Disease Control and Prevention, ethical
reference number 2014-001. All caregivers of infants provided written informed consent.

2.2. Data Collection

2.2.1. Questionnaires
We used standard questionnaires designed by the experts of NIPCPAC. The question-
naires were used to collect data regarding the essential characteristics of infants, including
sex and age. We also gathered information regarding their parents or caregivers, including
the level of education, ethnicity, and occupation. We also collected information regarding
feeding patterns and the status of 24-h complementary food intake based on the WHO [14].

2.2.2. Anthropometry
In the study, we used a body weight and height scale, which can display the results
of infants and children digitally. All weight and height scales selected by surveillance
counties must meet the national quality standards [15]. Body length was measured and
recorded with an accuracy of 0.1 cm. Body weight was measured in kilograms with an
accuracy of 0.05 kg.

2.3. Study Variables

We calculated the Z score using an Anthro Survey Analyzer and evaluated the nutri-
tional status of infants according to the WHO Child Growth Standard 2006. We used three
indicators: length for age (HAZ), weight for age (WAZ), and weight for height (WHZ). A
HAZ score <−2 was defined as stunting; a WAZ score <−2 was defined as underweight;
a WHZ score <−2 was defined as wasting. Overweight was defined as a WHZ score >2.
Any one or more of the above four conditions defined malnutrition. Malnutrition included
undernutrition and overnutrition.

2.4. Statistical Analysis

For analysis, the age of infants was categorized as 6–11 months (6–11 mon), 12–17 months
(12–17 mon), and 18–23 months (18–23 mon). We divided primary caregivers into groups
based on whether they were parents or grandparents. Education was categorized into three
Int. J. Environ. Res. Public Health 2021, 18, 8165 3 of 9

groups, i.e., those who had graduated from primary school or below (primary/below),
middle school, and high school or above (high school/above). The ethnicity of parents
was divided into Han and minorities. We divided birthweight into three groups: <2500 g
was the low birth weight (LBW), 2500~4000 g was the normal birth weight (NBW), and
≥4000 g was macrosomia (MW). We calculated the minimum diversity diet (MDD) based
on the WHO standard [16,17]. Occupation was divided into four groups: no work, work
related to agriculture, work related to the service sector, and other types of work.
We used the Pearson X2 test to compare binary and categorical variables. A multiple
logistic regression analysis was conducted to assess associated factors of stunting with
a forwarding likelihood ratio. To avoid collinearity, before the regression, we used the
collinearity test. In our study, the tolerance is much larger than 0.1, and the variance
inflation factor is less than 10, so there is no collinearity. The logistic regression model
included all potential influencing factors identified based on the chi-square test. All
statistical tests were 2-sided, and the significance level was set at less than 0.05. We
evaluated the associated factors of stunting via multiple logistic regression. The odds ratio
(OR) and 95% confidence intervals (CIs) were calculated. We carried out statistical analysis
using IBM SPSS Statistics for Windows, version 19 (IBM Corp., Armonk, NY, USA).

3. Results
3.1. Characteristics of Surveyed Children and Their Caregivers
Table 1 shows the characteristics of surveyed children and their caregivers. A total
of 17,193 6–23-month-old infants were enrolled. There were 8927 (51.9%) boys and 8266
(48.1%) girls. The number of people was roughly equal in each month group. Approxi-
mately 3.5% of infants were categorized as low birth weight, 5.4% were macrosomia, and
4.4% were preterm births. More than 80% of infants had not experienced fever or diarrhea
in the last two weeks. Roughly 92% of parents were of Han nationality, and around 8% of
parents were minorities. More than half of the parents had graduated from middle school,
and about 7.1% of mothers and 4.8% of fathers had primary education and below. Over
half of the mothers were homemakers, and 7.7% of mothers had jobs related to agriculture.
Approximately 90% of fathers were in work, and 74.4% of fathers were employed with
other jobs, such as in the service and manufacturing industries; only 15.4% of fathers had
jobs related to agriculture.

Table 1. Characteristics of surveyed children and their caregivers (n = 17,193).

Characteristic (n, %) Sample (n, %)

IYC
Months
6–11 months 5679 (33.0)
12–17 months 5689 (33.1)
18–23 months 5825 (33.9)
Sex
Boy 8927 (51.9)
Girl 8266 (48.1)
Preterm birth 764 (4.4)
Birth weight
<2500 g 607 (3.5)
2500 g~4000 g 15,653 (91.0)
≥4000 g 933 (5.4)
Two-week morbidity
Fever 1740 (10.1)
Diarrhea 1719 (10.0)
Mother
Ethnicity
Han 15,924 (92.6)
Int. J. Environ. Res. Public Health 2021, 18, 8165 4 of 9

Table 1. Cont.

Characteristic (n, %) Sample (n, %)

Education
Primary/below 1218 (7.1)
Middle school 9702 (56.5)
High school/above 6246 (36.4)
Occupation
No work 9531 (55.4)
Agriculture 1317 (7.7)
other work 6345 (36.9)
Father
Ethnicity
Han 15,892 (92.4)
Education
Primary/below 830 (4.8)
Middle school 9705 (56.4)
High school/above 6623 (38.5)
Occupation
No work 1766 (10.3)
Agriculture 2644 (15.4)
other work 12,783 (74.4)

3.2. Nutritional Status of 6–23-Month-Old Infants

Table 2 describes the mean and SD of nutritional status in the different age groups.
The overall mean body weight and length were 10.3 kg and 77.8 cm, and means for boys
were significantly higher than means for girls (p < 0.05). The mean of body length and
weight increased significantly with age. The overall mean of HAZ was highest in the
6–11-month-old infants, and it decreased significantly with age (p < 0.05). The overall mean
of HAZ in boys was significantly lower than in girls, and the trend was the same in each
age group. The means of WAZ, WHZ, and BMIZ decreased significantly with age, and the
highest means occurred in the 6–11-month-old age group.

Table 2. Nutritional status of 6–23-month-old infants.

Month Group (Mean ± SD)

Characteristic Gender Total p-Value
6–11 Months 12–17 Months 18–23 Months
Boy 9.4 ± 1.2 * 10.6 ± 1.2 * 11.7 ± 1.3 * 10.6 ± 1.5 * <0.001
Body weight (kg) 1 Girl 8.8 ± 1.1 10.0 ± 1.2 11.1 ± 1.3 10.0 ± 1.5 <0.001
Total 9.1 ± 1.2 10.3 ± 1.2 11.4 ± 1.3 10.3 ± 1.6 <0.001
Boy 72.2 ± 3.3 * 78.5 ± 3.5 * 84.1 ± 3.6 * 78.3 ± 6.0 * <0.001
Body length (cm) Girl 70.9 ± 3.3 77.4 ± 3.5 83.1 ± 3.6 77.2 ± 6.1 <0.001
Total 71.6 ± 3.4 78.0 ± 3.5 83.6 ± 3.6 77.8 ± 6.1 <0.001
Boy −0.02 ± 1.16 * −0.17 ± 1.15 * −0.32 ± 1.14 * −0.17 ± 1.16 * <0.001
HAZ Girl 0.13 ± 1.11 0.00 ± 1.05 −0.18 ± 1.03 −0.02 ± 1.07 <0.001
Total 0.06 ± 1.14 −0.09 ± 1.11 −0.25 ± 1.09 −0.10 ± 1.12 <0.001
Boy 0.14 ± 1.08 −0.05 ± 1.02 * −0.16 ± 0.98 * −0.02 ± 1.04 * <0.001
WAZ Girl 0.18 ± 0.98 0.05 ± 0.92 −0.08 ± 0.90 0.05 ± 0.94 <0.001
Total 0.16 ± 1.03 −0.01 ± 0.98 −0.12 ± 0.94 0.01 ± 0.99 <0.001
Boy 0.25 ± 1.14 0.04 ± 1.04 −0.00 ± 0.99 0.10 ± 1.06 <0.001
WHZ Girl 0.21 ± 1.04 0.06 ± 0.98 −0.03 ± 0.94 0.08 ± 0.99 <0.001
Total 0.23 ± 1.09 0.05 ± 1.01 −0.02 ± 0.97 0.09 ± 1.03 <0.001
Boy 0.20 ± 1.16 * 0.06 ± 1.06 0.06 ± 1.02 0.11 ± 1.08 <0.001
BMIZ Girl 0.14 ± 1.06 0.07 ± 0.99 0.04 ± 0.97 0.08 ± 1.01 <0.001
Total 0.17 ± 1.11 0.07 ± 1.03 0.05 ± 1.00 0.10 ± 1.05 <0.001
1 The t-test was used to compare the mean values of boys and girls, and p < 0.05 was marked as * located in the data of boys.
Int. J. Environ. Res. Public Health 2021, 18, 8165 5 of 9

3.3. Prevalence of Malnutrition in 6–23-Month-Old Infants

Table 3 presents the prevalence of malnutrition in 6–23-month-old infants based
on the factors of infants and parents. Amongst all infants, the prevalence of stunting
was the highest (3.9%), followed by overweight (3.0%), underweight (2.1%), wasting
(2.0%), and obesity (0.5%). The prevalence of stunting and underweight increased with
age, while overweight and fat had the opposite tendency (p < 0.05). The prevalence of
wasting fluctuated, having been found to be 2.2%, 1.9%, and 2.0% in the 6–11-month-old,
12–17-month-old, and 18–23-month-old groups, respectively. The prevalence of overweight
and obesity was the highest in 6–11-month-old infants and decreased with age. The
prevalence of malnutrition was much higher among boys than among girls, and each age
group had the same trend (p < 0.05).

Table 3. Prevalence of malnutrition among 6–23-month-old infants.

Month Group (n, %)

Malnutrition Prevalence Total p-Value
6–11 Month 12–17 Month 18–23 Month
Male 108 (3.6) 145 (4.9) 193 (6.4) 446 (5.0) <0.001
Stunting Female 57 (2.1) 71 (2.6) 101 (3.6) 229 (2.8) <0.001
Total 165 (2.9) 216 (3.8) 294 (5.0) 675 (3.9) <0.001
Male 71 (2.4) 86 (2.9) 80 (2.7) 237 (2.7) 0.454
Underweight Female 44 (1.6) 33 (1.2) 51 (1.8) 128 (1.5) 0.185
Total 115 (2.0) 119 (2.1) 131 (2.2) 365 (2.1) 0.693
Male 83 (2.8) 67 (2.3) 57 (1.9) 207 (2.3) 0.074
Wasting Female 44 (1.6) 42 (1.5) 57 (2.0) 143 (1.7) 0.351
Total 127 (2.2) 109 (1.9) 114 (2.0) 350 (2.0) 0.42
Male 139 (4.7) 85 (2.9) 72 (2.4) 296 (3.3) <0.001
Overweight Female 102 (3.8) 67 (2.5) 46 (1.6) 215 (2.6) <0.001
Total 241 (4.2) 152 (2.7) 118 (2.0) 511 (3.0) <0.001
Male 30 (1.0) 11 (0.4) 8 (0.3) 49 (0.5) <0.001
Obesity Female 21 (0.8) 8 (0.3) 5 (0.2) 34 (0.4) <0.001
Total 51 (0.9) 19 (0.3) 13 (0.2) 83 (0.5) <0.001

3.4. Associated Factors of Stunting in 6–23-Month-Old Infants

Table 4 shows the multivariate logistic analysis results associated with stunting among
6–23-month-old infants in poor rural areas. Girls (OR = 0.55, 95% CI (0.46, 0.65)) were asso-
ciated with a lower prevalence of stunting than boys. The prevalence of stunting increased
with age (OR = 1.05, 95% CI (1.03, 1.07)). Among infants who met the requirements for
minimum diversity diet (MDD), the prevalence of stunting decreased (OR = 0.81, 95% CI
(0.67, 0.98)). Infants whose mothers were minorities had a lower prevalence of stunting
than those with a mother of Han nationality (OR = 0.63, 95% CI (0.44, 0.90)). Mothers with
middle school (OR = 0.67, 95% CI (0.51, 0.88)) and high school or above (OR = 0.49, 95%
CI (0.37, 0.65)) education were less likely to be stunted. Mothers working in agriculture
(OR = 1.42, 95% CI (1.07, 1.89)) were at lower odds of stunting than homemakers. Paternal
occupation and education were not significantly associated with the prevalence of stunting.

Table 4. Multivariate logistic analysis 2 of stunting.

Variables β SE OR (95% CI) p-Value

Month 0.05 0.01 1.05(1.03, 1.07) <0.001
Gender −0.61 0.09 0.55(0.46, 0.65) <0.001
Mother Education <0.001
Middle school vs. primary/below −0.4 0.14 0.67(0.51, 0.88) <0.001
High/above vs. primary/below −0.72 0.15 0.49(0.37, 0.65) <0.001
Mother Occupation 0.07
Agriculture vs. Unemployed 0.35 0.14 1.42(1.07, 1.89) 0.01
Business vs. Unemployed −0.06 0.16 0.94(0.69, 1.28) 0.71
Others work vs. Unemployed −0.03 0.1 0.97(0.80, 1.18) 0.77
Mother minority −0.47 0.18 0.63(0.44, 0.90) 0.01
MDD 1 qualified −0.21 0.1 0.81(0.67, 0.98) 0.03
Constant −2.16 0.29 0.12 <0.001
1 MDD: minimum acceptable diet. 2 The model was controlled for birth weight and sickness in the last two weeks.
Int. J. Environ. Res. Public Health 2021, 18, 8165 6 of 9

4. Discussion
This study indicated the prevalence of malnutrition among 6–23-month-old infants
in poor rural areas of central China in 2019. We evaluated the prevalence of malnutrition
based on the WHO indicators of Child Growth Standards. There were 17,193 6–23-month-
old infants, and the prevalence of stunting was the highest (3.9%), followed by overweight
(3.0%), underweight (2.1%), wasting (2.0%), and obesity (0.5%). This was much better than
the prevalence of stunting (21.9%), wasting (7.3%), and overweight (5.9%) among children
under five years of age all over the world in 2018 [17]. More than half of the world’s stunted
children were in Asia [18]. However, the rate of stunting in China was much better than
that in other Asian countries among infants aged 0–23 months, such as India (33%) and
the Maldives (20%) [19]. We investigated the associated factors of stunting in parents and
infants via the multiple logistic regression model. The results showed that the prevalence
of stunting was associated with month, gender, complementary feeding, maternal ethnicity,
maternal occupation, and maternal educational level.
Multiple factors determine child growth. Quality complementary feeding is un-
doubtedly one of these determinants. In our study, the qualified MDD requirement is a
prospective factor of stunting. Infants older than six months need to have breastmilk and
are introduced complementary meals in time [20,21]. Globally, malnutrition of children is
primarily caused by inadequate feeding practices among infants and young children [2]. In
many poor areas of China, inadequate MDD was positively associated with a higher stunt-
ing rate among children aged 3 years old [22]. Based on 11 demographic and health surveys,
dietary diversity was significantly associated with HAZ and stunting [23]. Previous studies
have illustrated that a lack of dietary diversity will contribute to the malnutrition status of
infants, especially stunting [23–25]. Unfortunately, studies have shown that inappropriate
feeding practices for 6–23-month-old infants are common in many rural areas of China [26].
To improve the malnutrition status of 6–23-month-old infants, the government and relevant
departments should promote breastfeeding and scale up complementary feeding education
in poor rural areas.
The prevalence of stunting was found to be associated with the monthly age of
infants. Childhood undernutrition worsened with the increasing age of infants. The
prevalence of stunting increased with month, consistent with research results both in China
and abroad [3,22,27,28]. Our findings revealed that infants with mothers with higher
education levels were less likely to be stunted than those with mothers with primary school
education or below. In rural western China, the mother’s education level was negatively
associated with childhood undernutrition [27]. A parent with a lower education level
may have a low salary and little knowledge of feeding practices. Due to insufficient food
supplies and scientific feeding knowledge, parents may only introduce grain foods as
complementary food and breastmilk to infants [22]. However, in a study in Bangladesh, the
authors found that higher education among mothers and better household socioeconomic
conditions were not sufficient to decrease malnutrition rates among infants [29]. In our
study, infants of minority mothers had a lower prevalence of stunting than those with
Han parents, which was inconsistent with the findings of past studies [4,27]. In previous
research, ethnic minorities, including Tibetan, Uighur, and Yi, were associated with a higher
prevalence of stunting due to inconvenient traffic infrastructure, low income, and limited
food resources [30].
Malnutrition includes undernutrition and overnutrition, such as overweight and
obesity [1]. In our study, the prevalence of overweight and obesity decreased compared
with 10% of overweight among 2–6-year-old children in the 2009–2011 China Health and
Nutrition Survey [31]. Overweight and obese infants are becoming an increasingly se-
vere contributor to adult obesity, diabetes, and chronic diseases [8]. Few studies have
recognized the problem of double burden in malnutrition in impoverished areas in China.
In low-income groups, overweight and obesity prevalence was 13.5% and 9.9%, respec-
tively, among 2–6-year-old children in 2011 [31]. In children under five, the prevalence of
overweight was 5.4% in a poor midwestern China area in 2009, which represents a newly
Int. J. Environ. Res. Public Health 2021, 18, 8165 7 of 9

emerging problem [31]. The prevalence of overweight was found to be higher in urban
and high-income areas in past research [31]. Given that child malnutrition in poor rural
areas is often ignored, we should provide nutritional education including guidance around
controlling undernutrition and overnutrition to parents at the same time.
A strength of our study was that we first used the data of 6–23-month-old infants to
assess malnutrition in poor rural areas in central China in 2019. Additionally, our data
came from the national program, and so, they were of good quality and high reliability.
One potential limitation is that the causal relationships between sociodemographic charac-
teristics and stunting need more analysis to confirm the cross-sectional design of this study.
In addition, family income and the weight and height of mothers were not assessed in our
questionnaire. Because the prevalence of malnutrition was different in each month group,
we would analyze the associated factors of stunting in 6–11 month, 12–17 month and 18–23
month infants in the future, respectively.

5. Conclusions
In conclusion, our study showed the prevalence of stunting; wasting; and underweight,
overweight, and obesity among 6–23-month-old infants in poor areas of central China
in 2019. Malnutrition is a complex problem affected by a range of determinants. Infant
age, male gender, inadequate MDD, and lower education level of mothers were risk
factors for stunting. Specifically, infants in rural areas of China need additional and earlier
monitoring to detect and prevent undernutrition, fundamentally reducing the overall
burden of undernutrition. Follow-up studies may comprehensively consider nutritional
status in the first 1000 days of life, such as collecting more information on pregnancy and
the status of mothers.

Author Contributions: Methodology, J.L.; formal analysis, J.L.; writing—original draft preparation,
J.L.; writing—review and editing, J.L., J.H. (Junsheng Huo), J.S. and J.H. (Jian Huang); supervision,
J.H. (Junsheng Huo); project administration, J.S. and J.H. (Jian Huang). All authors have read and
agreed to the published version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: The study was conducted according to the guidelines of the
Declaration of Helsinki and was approved by the Ethical Committee of the National Institute for
Nutrition and Health in Chinese Center for Disease Control and Prevention (protocol code 2014-001).
Informed Consent Statement: Informed consent was obtained from all subjects involved in the study.
Data Availability Statement: The datasets presented in this article are not readily available because
of the regulations of Data Management in the Chinese Center for Disease Control and Preven-
tion. Requests to access the datasets should be directed to the National Institute for Nutrition
and Health, Chinese Center for Disease Control and Prevention, the email address of which is
[email protected].
Acknowledgments: We would like to express our sincere thanks to all of the professors and col-
leagues who contributed to the collection of the data. We are also grateful to the data collectors for
their cooperation during the entire process of data collection.
Conflicts of Interest: The authors declare no conflict of interest.

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