Double burden or double counting of child malnutrition? The methodological and theoretical implications of stuntingoverweight in low and middle income countries

The Value of an Ecological Approach to Improve the Precision of Nutritional Assessment: Addressing Contributors and Implications of the "Multiple Burdens of Malnutrition"

Globally, children are exposed to multiple health risks associated with diet and nutrition. Rather than simply being a condition of having too much or too little food, malnutrition is more a syndrome comprising multiple burdens of coexisting and reciprocal malnutrition, infection, or other conditions. Importantly, children with such syndromes (e.g., stunting and anemia, which are neither specific nor necessarily sensitive to nutritional status) are more likely to also have irreversible functional outcomes such as poor growth, impaired immune function, or cognitive delays. The global health community has identified nutrition-related targets (e.g., Sustainable Development Goals (SDGs) and World Health Organization (WHO) Global Nutrition Targets) that, for multiple reasons, are difficult to address. Moreover, as the complexity of the global health context increases with persistent pandemics of infectious diseases and the rising prevalence of noncommunicable diseases, there is a growing appreciation that conditions selected as nutrition/health targets indeed represent syndromes for which nutritional status serves as both an input and outcome. In recognition of the impact of these combined challenges and the role of the multiple manifestations of malnutrition, we suggest an approach to nutritional assessment that is intended to improve the precision of context-specific, equitable approaches to health promotion, disease prevention, and treatment.

Gender-specific disaggregated analysis of childhood undernutrition in Ethiopia: evidence from 2000-2016 nationwide survey

INTRODUCTION

Childhood undernutrition has been investigated extensively in previous literature but gender inequality detailing the burden of undernutrition has not been adequately addressed in scientific papers, especially in Ethiopia, where undernutrition is known to be a public health problem of high significance, necessitating increased efforts to address it and reduce this inequality. This study was carried out to: (1) explore gender differences in the prevalence of stunting, wasting, and underweight, and (2) compare the factors associated with childhood undernutrition between boys and girls in Ethiopia.

METHODS

The study used a dataset of more than 33,564 children aged under 5 years (boys: 17,078 and girls: 16,486) who were included in the nationally representative Ethiopia Demographic and Health Survey (EDHS) from 2000 to 2016. The outcome variables were anthropometric indices: stunting (height-for-age < -2 standard deviations), wasting (weight-for-height < -2 standard deviations), and underweight (weight-for-age < -2 standard deviations). Gender-specific multilevel analyses were used to examine and compare the factors associated with child undernutrition.

RESULTS

The overall prevalence of stunting (49.1% for boys vs 45.3% for girls, p < 0.001), wasting (11.9% for boys vs 9.9% for girls, p < 0.001), and underweight (33.1% for boys vs 29.8% for girls, p < 0.001) higher among boys compared to girls. Boys significantly had higher odds of stunting (aOR: 1.31, 95%CI: 1.21-1.42), wasting (aOR: 1.35, 1.23-1.48), and underweight (aOR: 1.38, 95%CI: 1.26-1.50) than girls. The common factors associated with childhood undernutrition for male and female children were the child's age, perceived size of the child at birth, breastfeeding status, maternal stature, maternal education, toilet facility, wealth index, and place of residence. Boys who were perceived by their mothers to be average sized at birth and were born to uneducated mothers had a higher likelihood of experiencing wasting, in contrast to girls. Among boys, birth order (firstborn), household size (1-4), and place of residence (urban) were associated with lower odds of being underweight. Boys living in cities had lower odds of being stunted. While girls born to mothers with no education and worked in agriculture were at a higher odd of being stunted.

CONCLUSION

Our study revealed that boys were more likely to be malnourished than girls, regardless of their age category, and there were variations in the factors determining undernutrition among boys and girls. The differences in the burden of undernutrition were significant and alarming, positioning Ethiopia to be questioned whether it will meet the set Sustainable Development Goals (SDGs), including SDG 2 of zero hunger by 2030. These findings call for more effort to address malnutrition as a significant public health issue in Ethiopia, and to urgently recognise the need for enhanced interventions that address the gender gap in childhood undernutrition.

Physico-functional and nutritional characteristics of germinated pigeon pea (Cajanus cajan) flour as a functional food ingredient

The study investigated the effect of germination on pigeon pea flour's physico-functional (pH, color, water and oil absorption capacities, swelling and foaming capacities and bulk densities) and proximate, total polyphenols and antioxidant activity. The physico-functional and proximate parameters were determined using standard protocols. The color analysis showed that germination significantly increased the flour samples' lightness (L*) (70.7; p = 0.009) by almost 1.5-fold. Germination resulted in almost 1.1 times higher oil absorption capacity than the control (219.9%; p = 0.022). The foaming capacity of the germinated samples significantly (p = 0.015) increased by 6.4%. Germination significantly reduced the loose bulk density (0.54 vs 0.63; p = 0.012) but significantly increased the tapped bulk density (0.84 vs 0.77; p = 0.002). The germinated samples recorded significantly (1.62%; p = 0.010) lower crude fat, about 1.2 times lower than the raw flour. Germination significantly increased the flour's total ash (4.2% vs 3.6%; p = 0.003) and crude protein (11.6% vs 9.4%; p = 0.047) content. Germinated pigeon pea flour will perform better in formulating baked products, aerated foods and food extenders than non-germinated pigeon pea flour. Hence, the germination of pigeon peas should be encouraged because it harnesses the functional and proximate attributes measured.

Unhealthy food consumption and its associated factors among infants and young children in Gondar city, northwest Ethiopia: a community based cross sectional study

INTRODUCTION

Many low- and middle-income countries are now shifting toward diets that are higher in added sugars, unhealthy fats, salt, and refined carbohydrates. Childhood obesity and chronic diseases have all been linked to unhealthy food consumption. Despite this, the majority of Ethiopian infants and children consume unhealthy food. There is also a scarcity of evidence. Therefore, the objective of this study was to assess the prevalence of unhealthy food consumption and its associated factors among children ages 6-23 months in Gondar City, northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted from June 30 to July 21, 2022, in Gondar city. Multistage sampling was used to select 811 mother-child pairs. Food consumption was measured through a 24-hour recall. Data were entered into EpI Data 3.1 before being exported to STATA 14 for further analysis. A multivariable logistic regression analysis was employed to identify the factors associated with unhealthy food consumption. An adjusted odds ratio (AOR) with a 95% confidence interval was used to show the strength of the association, while a P-value of 0.05 was used to declare the significance of the association.

RESULTS

The percentage of children with unhealthy food consumption was 63.7% (95% CI: 60.4%, 67.2%). Maternal education [AOR = 1.89, 95% CI = 1.05, 3.69], living in an urban residence [AOR = 4.55, 95% CI = 3.61, 7.78], GMP service [AOR = 2.07, 95% CI = 1.48, 3.18], age of the child 18-23 months [AOR = 0.53, 95% CI = 0.34, 0.74], and family size of more than four [AOR = 1.22, 95% CI = 1.07, 2.78] were significantly associated with unhealthy food consumption.

CONCLUSION

In Gondar City, nearly two thirds of infants and children received unhealthy food. Maternal education, urban residence, GMP service, child age, and family size were all significant predictors of unhealthy food consumption. Thus, improving the uptake of GMP services and family planning services is critical to reducing unhealthy food consumption.

The coexistence of stunting and overweight or obesity in Ethiopian children: prevalence, trends and associated factors

BACKGROUND

Double burden of childhood malnutrition is a condition where undernutrition (stunting) along with overweight and obesity coexist within individuals, households, and populations. It reflects a new layer of malnutrition and an understudied phenomenon in many low-income settings. To date, the prevalence and factors that are associated with concurrent stunting and overweight or obesity (overweight/obesity) (CSO) in the same children have not been well researched in Ethiopia. Hence, this study aimed to assess the prevalence, trends, and factors associated with the coexistence of stunting and overweight or obesity among children aged 0-59 months in Ethiopia.

METHODS

Pooled data from 2005, 2011 and 2016 Ethiopian Demographic and Health Survey (EDHS) were used. A total of 23,756 (weighted sample) children aged 0-59 months were included in the study. Height-for-age z-scores (HAZ) less than - 2 SD and weight-for-height z-scores (WHZ) above 2 SD were calculated, and children were classified as stunted and overweight/obese, respectively. A child who is simultaneously stunted and overweight/obese was considered as having HAZ below - 2 SD and WHZ above 2 SD computed into a variable named CSO, and reported as a binary outcome (yes or no). Multilevel logistic regression analysis that adjusts for sampling weights and clustering was used to identify factors associated with CSO.

RESULTS

The prevalence of stunting, overweight or obesity, and CSO among under-five children was 43.12% [95% CI: (42.50, 43.75%)], 2.62% [95% CI: (2.42, 2.83%)], and 1.33% [95% CI: (1.18, 1.48%)], respectively. The percentage of CSO children was reported to have declined from 2.36% [95% CI: (1.94-2.85)] in 2005 to 0.87% [95%CI: (0.07-1.07)] in 2011, and the same appeared to have increased slightly to 1.34% [95%CI: (1.13-1.59)] in 2016. Children who were currently breastfeeding [AOR: 1.64, 95%CI: (1.01-2.72)], born to an overweight mother [AOR: 2.65, 95%CI: (1.19-5.88)], and lived in families with 1-4 household members [AOR: 1.52, 95%CI: (1.02-2.26)] were significantly associated with CSO. At the community level the odds of having CSO were higher among children included from EDHS-2005 [AOR: 4.38, 95%CI: (2.42-7.95)].

CONCLUSION

The study revealed that less than 2% of children had CSO in Ethiopia. CSO was linked to factors at both the individual (i.e. breastfeeding status, maternal overweight, and household size) and community-levels. Overall, the study findings indicated the necessity of focused interventions to simultaneously address double burden of childhood malnutrition in Ethiopia. To further combat the double burden of malnutrition, early identification of at-risk children, including those born to overweight women and children living with multiple household members, is indispensable.

Association between maternal stature and household-level double burden of malnutrition: findings from a comprehensive analysis of Ethiopian Demographic and Health Survey

BACKGROUND

Undernutrition among under-five children is one of the intractable public health problems in Ethiopia. More recently, Ethiopia faced a rising problem of the double burden of malnutrition-where a mother may be overweight/obese, and a child is stated as having undernutrition (i.e., stunting, wasting, or underweight) under the same roof. The burden of double burden of malnutrition (DBM) and its association with maternal height are not yet fully understood in low-income countries including Ethiopia. The current analysis sought: (a) to determine the prevalence of double burden of malnutrition (i.e., overweight/obese mother paired with her child having one form of undernutrition) and (b) to examine the associations between the double burden of malnutrition and maternal height among mother-child pairs in Ethiopia.

METHODS

We used population-representative cross-sectional pooled data from four rounds of the Ethiopia Demographic and Health Survey (EDHS), conducted between 2000 and 2016. In our analysis, we included children aged 0-59 months born to mothers aged 15-49 years. A total of 33,454 mother-child pairs from four waves of EDHS were included in this study. The burden of DBM was the primary outcome, while the maternal stature was the exposure of interest. Anthropometric data were collected from children and their mothers. Height-for-age (HFA), weight-for-height (WFH), and weight-for-age (WFA) z-scores < - 2 SD were calculated and classified as stunted, wasting, and underweight, respectively. The association between the double burden of malnutrition and maternal stature was examined using hierarchical multilevel modeling.

RESULTS

Overall, the prevalence of the double burden of malnutrition was 1.52% (95% CI 1.39-1.65). The prevalence of overweight/obese mothers and stunted children was 1.31% (95% CI 1.19-1.44), for overweight/obese mothers and wasted children, it was 0.23% (95% CI 0.18-0.28), and for overweight/obese mothers and underweight children, it was 0.58% (95% CI 0.51-0.66). Children whose mothers had tall stature (height ≥ 155.0 cm) were more likely to be in the double burden of malnutrition dyads than children whose mothers' height ranged from 145 to 155 cm (AOR: 1.37, 95% CI 1.04-1.80). Similarly, the odds of the double burden of malnutrition was 2.98 times higher for children whose mothers had short stature (height < 145.0 cm) (AOR: 2.98, 95% CI 1.52-5.86) compared to those whose mothers had tall stature.

CONCLUSIONS

The overall prevalence of double burden of malnutrition among mother-child pairs in Ethiopia was less than 2%. Mothers with short stature were more likely to suffer from the double burden of malnutrition. As a result, nutrition interventions targeting households' level double burden of malnutrition should focus on mothers with short stature to address the nutritional problem of mother and their children, which also has long-term and intergenerational benefits.

Concurrent wasting and stunting among children 6-59 months: an analysis using district-level survey data in Mozambique

Background

In the past it was believed that wasting and stunting were independent of each other. Recent work has shown that they can occur concurrently in a child and that increases considerably the risk of mortality. Concurrent wasting and stunting (WaSt) is currently defined as WHZ < -2 AND HAZ < -2. Wasting is measured by WHZ and MUAC and evidence shows that they tend to identify different sets of children. Our study aimed to look at the effect of adding MUAC on the prevalence and burden of WaSt, and to assess diagnosis of WaSt with a single measurement.

Methods

We analyzed population-based anthropometric surveys from 37 districts in Mozambique conducted by the Government of Mozambique between 2017 and 2019. We proposed a new case-definition for WaSt that includes MUAC in acknowledgement of the different children with wasting diagnosed by WHZ and MUAC. We estimated how many WaSt cases are eligible to be included in the existing treatment program in Mozambique by calculating the True Positive and False Positive Values of WaSt using our proposed case-definition against the wasting admission criteria. AUC of ROC curves used for MUAC and WAZ and optimal cut-offs were determined using Youden’s Index.

Results

Including MUAC in the concurrent WaSt case-definition identified more children with WaSt compared to the original case-definition and more younger children and girls were identified. Using both MUAC and WHZ and enrolling severe and moderate wasting is already picking up most of the WaSt cases: 100% in health facilities and 79.40% with MUAC mass screenings at community level. Cut-off values from the ROC curve for the proposed case-definition were MUAC ≤133 mm and WAZ ≤ 2.145 Z-scores, however, they  yielded many false positive values.

Conclusion

WaSt case-definition should include MUAC. WaSt should commence to be reported in surveys and Mozambique should also start monitoring and treating children with WaSt. A cost-effective approach to identify all children with WaSt without adding too many false positive is needed, as well as understanding how to achieve optimal treatment outcomes within existing programs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40795-022-00508-9.

Social networking sites: a new source of child feeding information for parents in Thailand

Social networking sites (SNSs) provide opportunities for health and nutrition communication. Data are lacking on whether these SNSs influence Thai parent's food provisioning to young children. In the current study, we examined the prevalence and characteristics of Thai parents who reported participating in child food and nutrition-SNSs and investigated the association between participation in these sites and parents' perceptions and feeding practices. A sample of 379 Thai parents completed a survey about the use of child food and nutrition-SNSs, and feeding practices and child eating behavior. Around 70% of participants, especially female millennials with their first child, have participated in SNSs that provide information about children's diets. High engagement was more common among younger and less educated participants, as well as rural dwellers and those with abnormal body mass index. Among these SNSs' participants, those with higher engagement had higher levels of trust in the nutritional information shared on SNSs. Further analyses showed that parents who have joined these sites had positive associations with not only providing children with more fresh fruits and vegetable but also more processed meats. Further investigations are needed to explore the information these SNSs provided and what influences they have on parents' perceptions around feeding children.

Double burden of malnutrition and its association with infant and young child feeding practices among children under-five in Thailand

OBJECTIVE

This study examined the prevalence of stunting-overweight and socio-demographic determinants among children under-five years of age, as well as associations with infant and young child feeding (IYCF) among children aged 6-23 months.

DESIGN

Secondary data analysis based on the Thailand Multiple Indicator Cluster Survey 2015-2016.

SETTING

Cross-national study.

PARTICIPANTS

Nationally representative sample of children under-five years of age (n 12 313).

RESULTS

The prevalence of wasting, stunting, overweight and stunting-overweight was 5·3, 10·5, 10·1 and 1·6 %, respectively. In multivariate analyses, children under 6 months, children from low and middle wealth tertiles, and children living in rural areas were prone to being wasted. Male children, low wealth tertile and a non-Thai speaking household head were positively and children aged 48-59 months and a one-child household were inversely associated with stunting. Children from a low wealth tertile were less likely to be overweight, while older age, male children and children from a one-child household were more likely to be overweight. Stunting-overweight was associated with children aged 24-47 months, male children, mothers having secondary education, a one-child household, a non-Thai speaking household head and an urban area. In terms of IYCF indicators, despite no association with stunting and stunted-overweight children, current breast-feeding and inadequate meal frequency were associated with being wasting, while current breast-feeding and dietary diversity were inversely associated with being overweight.

CONCLUSIONS

This study revealed the double burden of malnutrition at the individual and population levels among Thai children under-five, which calls for concrete integrated interventions to tackle all forms of malnutrition.

Stunting, wasting, overweight and their coexistence among children under 7 years in the context of the social rapidly developing: Findings from a population-based survey in nine cities of China in 2016

The prevalence of stunting, wasting, overweight and their coexistence are various in different populations and they also have changed with social developing and environmental improving. In this paper, we aimed to analyze the prevalence of stunting, wasting, overweight and their coexistence in some developed regions of China. Data were collected in a population-based cross-sectional survey by a multi-stage cluster sampling method in nine cities located in the northern, central, and southern region of China in 2016. Children under seven years (n = 110,491) were measured. WHO growth standards were used to assess the growth status. Stunting, underweight, wasting, overweight and obesity were considered as the primary forms of malnutrition (includes undernutrition and overnutrition) for infant or young children at population-levels. The prevalence of stunting, underweight, wasting, and overweight or obesity were respectively 0.7%, 0.6%, 1.2%, and 7.6%. Most of these children (95.4%) suffered from one form of malnutrition, and only 0.2% of them concurrently stunted and wasted, 0.4% concurrently stunted and overweight, 1.7% concurrently stunted and underweight, 2.3% concurrently underweight and wasted. Among stunted children, 91.2% were appropriate body proportion, and only 2.3% were wasted, 6.5% were overweight or obesity. Among overweight or obese children, only 0.6% were stunted, whereas, 15.8% were high stature and 83.6% were the appropriate ranges of stature. Sex, age, urban/suburban, and region were associated with these primary forms of malnutrition in the multivariate logistic analysis. In conclusion, we found that the coexistence of stunting and overweight was not common at both population-level and individual-level. The situation for undernutrition had significantly improved, and overweight may be the leading public health issue for children under seven years in the nine cities of China.

Maternal height and double-burden of malnutrition households in Mexico: stunted children with overweight or obese mothers

OBJECTIVE

To assess the association between short maternal height and four types of mother-child nutritional status groupings within Mexican households.

DESIGN

We classified mother-child dyads into four groups: stunted child and a non-overweight/non-obese mother (stunting-only), non-stunted child and an overweight/obese mother (overweight-only), stunted child with an overweight/obese mother (double-burden) and households with neither child stunting nor overweight/obese mothers (neither-condition). We assessed the association between maternal height and mother-child nutrition status using multinomial logistic regression, controlling for socio-economic covariates.

SETTING

Nationally representative cross-section of households from the 2012 Mexican National Health and Nutrition Survey.

PARTICIPANTS

Children <5 years of age were matched to their mothers, resulting in a sample of 4706 mother-child dyads.

RESULTS

We found that among children with stunting, 53·3% have an overweight/obese mother. Double-burden was observed in 8·1% of Mexican households. Maternal short stature increased the probability of stunting-only by 3·5% points (p.p.) and double-burden by 9·7 p.p. (P < 0·05). The inverse association was observed for overweight-only and neither-condition households, where the probability of these outcomes decreased by 7·2 and 6 p.p. in households with short-statured mothers (P < 0·05), respectively.

CONCLUSIONS

Women with short stature are more likely to develop overweight and simultaneously have a stunted child than those who are not short-statured. Our findings underline the challenges faced by public health systems, which have to balance the provision of services for both an undernourished and increasingly overweight/obese population.

Maternal height and double-burden of malnutrition households in Mexico: stunted children with overweight or obese mothers

OBJECTIVE

To assess the association between short maternal height and four types of mother-child nutritional status groupings within Mexican households.

DESIGN

We classified mother-child dyads into four groups: stunted child and a non-overweight/non-obese mother (stunting-only), non-stunted child and an overweight/obese mother (overweight-only), stunted child with an overweight/obese mother (double-burden) and households with neither child stunting nor overweight/obese mothers (neither-condition). We assessed the association between maternal height and mother-child nutrition status using multinomial logistic regression, controlling for socio-economic covariates.

SETTING

Nationally representative cross-section of households from the 2012 Mexican National Health and Nutrition Survey.

PARTICIPANTS

Children <5 years of age were matched to their mothers, resulting in a sample of 4706 mother-child dyads.

RESULTS

We found that among children with stunting, 53·3% have an overweight/obese mother. Double-burden was observed in 8·1% of Mexican households. Maternal short stature increased the probability of stunting-only by 3·5% points (p.p.) and double-burden by 9·7 p.p. (P < 0·05). The inverse association was observed for overweight-only and neither-condition households, where the probability of these outcomes decreased by 7·2 and 6 p.p. in households with short-statured mothers (P < 0·05), respectively.

CONCLUSIONS

Women with short stature are more likely to develop overweight and simultaneously have a stunted child than those who are not short-statured. Our findings underline the challenges faced by public health systems, which have to balance the provision of services for both an undernourished and increasingly overweight/obese population.

The Double Burden of Malnutrition: A Systematic Review of Operational Definitions

BACKGROUND

Despite increasing research on the double burden of malnutrition (DBM; i.e., coexisting over- and undernutrition), there is no global consensus on DBM definitions.

OBJECTIVES

To identify published operational DBM definitions, measure their frequency of use, and discuss implications for future assessment.

METHODS

Following a structured search of peer-reviewed articles with terms describing "overnutrition" [e.g., overweight/obesity (OW/OB)] and "undernutrition" (e.g., stunting, micronutrient deficiency), we screened 1920 abstracts, reviewed 500 full texts, and extracted 623 operational definitions from 239 eligible articles.

RESULTS

We organized three identified DBM dimensions (level of assessment, target population, and forms of malnutrition) into a framework for building operational DBM definitions. Frequently occurring definitions included coexisting: 1) OW/OB and thinness, wasting, or underweight (n = 289 occurrences); 2) OW/OB and stunting (n = 161); 3) OW/OB and anemia (n = 74); and 4) OW/OB and micronutrient deficiency (n = 73).

CONCLUSIONS

Existing DBM definitions vary widely. Putting structure to possible definitions may facilitate selection of fit-for-purpose indicators to meet public health priorities.

The double burden of malnutrition in under-five children at national and individual levels: observed and expected prevalence in ninety-three low- and middle-income countries

Objective

To assess whether the observed prevalence of the double burden of malnutrition (DBM) would be higher than expected on the basis of chance, through analyses at national, wealth quintile and individual child levels.

Design

We selected nationally representative surveys from low- and middle-income countries (LMIC) carried out since 2005 with anthropometric measures on children under 5 years of age. Household wealth was assessed through asset indices. The expected prevalence of DBM was estimated by multiplying the prevalence of stunting (low height/length for age) and overweight (high weight for height/length). The WHO recommended cut-offs (20% for stunting and 10% for overweight) that were used to define DBM at national level. DBM at individual level was defined as co-occurrence of stunting and overweight in the same child.

Setting

Nationally representative surveys from ninety-three LMIC.

Participants

A total of 825 633 children were studied.

Results

DBM at national level was observed in five countries, whereas it would be expected to occur in eleven countries. Six countries did not present evidence of DBM at national level but did so in at least one wealth quintile. At individual level, thirty countries (32·3%) showed higher prevalence of DBM than would be expected, but most differences were small except for Syria, Azerbaijan, Albania and Egypt.

Conclusions

The observed number of countries or socio-economic subgroups within countries with the DBM using recommended thresholds was below what would be expected by chance. However, individual-level analyses showed that one-third of countries presented higher prevalence of DBM than would be expected.

Nutrition transition and double burden of malnutrition in Africa: A case study of four selected countries with different social economic development

Background

Disease and lifestyle patterns have been changing rapidly especially in Africa due to transformation in economic development and urbanization. Research on the magnitude and consequences of these transformations in Africa is limited. This study investigates the shifts in nutritional status in children and adults in four selected low-, middle- and high-income countries in Africa, identifies factors associated with the shifts, and provides recommendations for future studies.

Methods

Malawi, Kenya, Ghana, and South Africa were selected based on their Gross Domestic Product (GDP). Nationally representative data were obtained from the 2017 Global Nutrition Report, Demographic Health Surveys (DHSs), and the World Health Organization (WHO) database. Prevalence of underweight, overweight, and obesity were assessed and compared across the countries, gender, residence, and over time. Results: South Africa had the highest GDP and largest prevalence of overweight and obesity rates in children < 5 years old and adults > 18 (13.3% and 51.9%, respectively). Malawi, with the lowest GDP, had the highest stunting rate (37.0%). In all 4 countries, but most notably in South Africa, trends indicated that the increasing prevalence of overweight and obesity was much greater than the declining rate of underweight. Malawi, Kenya, and Ghana had a slight decline in overweight prevalence in children under 5 years.

Conclusions

Nutritional shifts are occurring in Africa and seem to be heavily influenced by economic development. The double-burden of malnutrition presents prioritization challenges for policymakers. Attention needs to be shifted towards prevention of obesity, at least in the higher income countries in Africa.

Double burden of malnutrition in children aged 24 to 59 months by socioeconomic status in five South Asian countries: evidence from demographic and health surveys

OBJECTIVES

We aimed to investigate the socioeconomic inequalities in the burden of underweight and overweight among children in South Asia. We also examined other factors that were associated with these outcomes independently of household's socioeconomic status.

DESIGN

Nationally-representative surveys.

SETTINGS

Demographic and Health Surveys from Bangladesh, India, Pakistan, Maldives and Nepal, which were conducted between 2009 and 2016.

PARTICIPANTS

Children aged 24 to 59 months with valid measurement for height and weight (n=146 996).

PRIMARY EXPOSURE AND OUTCOME MEASURES

Primary exposures were household's wealth index and level of education. Underweight and overweight were defined according to the WHO and International Obesity Task Force definitions, respectively.

RESULTS

Underweight prevalence was 37% in Bangladesh, 38% in India, 19% in Maldives, 29% in Nepal and 28% in Pakistan. Bangladesh, India and Nepal had similar overweight prevalence (between 2% and 4%) whereas Pakistan (7%) and Maldives (9%) had higher prevalence. Households with higher wealth index or education had lower odds of having underweight children. Adjusted ORs of underweight for richest versus poorest households were 0.4 (95% CI: 0.3 to 0.5), 0.5 (95% CI: 0.5 to 0.6), 0.5 (95% CI: 0.2 to 1.4), 0.5 (95% CI: 0.3 to 0.8) and 0.7 (95% CI: 0.5 to 1.1) for Bangladesh, India, Maldives, Nepal and Pakistan, respectively. Compared with poorest households, richest households were more likely to have overweight children in all countries except Pakistan, but such associations were not significant after adjustment for other factors. There were higher odds of having overweight children in households with higher education in Bangladesh (OR 2.1 (95% CI: 1.3 to 3.5)), India (OR 1.2 (95% CI: 1.2 to 1.3)) and Pakistan (OR 1.8 (95% CI: 1.1 to 2.9)) when compared with households with no education. Maternal nutritional status was consistently associated with children's nutritional outcomes after adjustments for socioeconomic status.

CONCLUSIONS

Our study provides evidence for socioeconomic inequalities for childhood underweight and overweight in South Asian countries, although the directions of associations for underweight and overweight might be different.

Child-level double burden of malnutrition in the MENA and LAC regions: Prevalence and social determinants

Although the prevalence of obesity has rapidly increased in the low‐ and middle‐income countries of the Middle East and North Africa (MENA) and Latin America and the Caribbean (LAC) regions, child undernutrition remains a public‐health challenge. We examined region‐specific sociodemographic determinants of this double burden of malnutrition, specifically, the co‐occurrence of child stunting and overweight, using Demographic and Health Survey and Multiple Indicator Cluster Survey data (2003–2016) from 11 countries in the MENA (n = 118,585) and 13 countries in the LAC (n = 77,824) regions. We used multiple logistic regressions to model region‐specific associations of maternal education and household wealth with child nutritional outcomes (6–59 months). The prevalence of stunting, overweight, and their co‐occurrence was 24%, 10%, and 4.3% in children in the MENA region, respectively, and 19%, 5%, and 0.5% in children in the LAC region, respectively. In both regions, higher maternal education and household wealth were significantly associated with lower odds of stunting and higher odds of overweight. As compared with the poorest wealth quintiles, decreased odds of co‐occurring stunting and overweight were observed among children from the second, third, and fourth wealth quintiles in the LAC region. In the MENA region, this association was only statistically significant for the second wealth quintile. In both regions, double burden was not statistically significantly associated with maternal education. The social patterning of co‐occurring stunting and overweight in children varied across the two regions, indicating potential differences in the underlying aetiology of the double burden across regions and stages of the nutrition transition.

Provincial Dietary Intake Study (PDIS): Prevalence and Sociodemographic Determinants of the Double Burden of Malnutrition in A Representative Sample of 1 to Under 10-Year-Old Children from Two Urbanized and Economically Active Provinces in South Africa

The objective of this study was to determine the prevalence and socio-demographic predictors of malnutrition in two urbanized economically active provinces (Gauteng N = 733, Western Cape N = 593) in South Africa. A multistage stratified cluster random sampling design was applied. Fieldworkers visited homes, measured children aged 1-<10-years old (N = 1326) and administered a questionnaire (mother/primary caregiver). In under-five year old children (N = 674) 21.6% were stunted [height-for-age z-score < −2 SD], 5.6 % underweight [weight-for-age z-score < −2 SD], 10.3% overweight (body mass index-for-age z-score) (BAZ)> +2 SD ≤ +3 SD] and 7.0% obese (BAZ > +3 SD). In 5–<10-year olds (N = 626) 6.7% were stunted, 6.8% underweight, 13.4% overweight and 6.8% obese. Stunting and overweight in the same child was present in 5.7% under-five year olds and 1.7% in 5–<10-year olds. Multiple logistic regression analyses identified having a mother with a post-grade 12 qualification (OR = 0.34) and having an obese mother (OR 0.46) as protectors and being in the under-five age group (OR = 3.73) as a risk factor for stunting. Being in the under-five age group was also a risk factor for a BAZ > 1 (OR 2.39), while being in the third wealth quintile was protective (OR = 0.62). Results indicate that stunting and overweight/obesity are still present at concerning levels, especially in the under-five age group.

Double burden of malnutrition at household level: A comparative study among Bangladesh, Nepal, Pakistan, and Myanmar

BACKGROUND

The coexistence of overweight mother and stunted child at the same household is a type of Double Burden of Malnutrition at Household Level (DBMHL). This particular public health concern is now emerging at an alarming rate among most of the South Asian and its neighboring lower-and-middle income countries which are going through nutritional transition. This study has examined the prevalence rate and the risk factors of DBMHL along with the socio-economic inequality in DBMHL among Bangladesh, Nepal, Pakistan, and Myanmar.

METHODS

Latest Demographic and Health Survey datasets were used in this study. To identify the significant association of DBMHL with socio-demographic characteristics, a multivariate technique named as logistic regression model, and for measuring socio-economic inequalities in DBMHL prevalence, relative index of inequality (RII) and slope index of inequality (SII) were used.

RESULTS

The prevalence rates of DBMHL were 4.10% (urban: 5.57%, rural: 3.51%), 1.54% (urban: 1.63%, rural: 1.42%), 3.93% (urban: 5.62%, rural: 3.20%), and 5.54% (urban: 6.16%, rural: 5.33%) respectively in Bangladesh, Nepal, Pakistan, and Myanmar. The risk ratios (RR) obtained from RII for Bangladesh, Nepal, Pakistan and Myanmar were 1.25, 1.25, 1.14, and 1.09, respectively, and β coefficient from SII were 0.01, 0.004, 0.005, and 0.006 unit respectively. In addition to not breastfeeding [Bangladesh (AOR: 1.55; 95% CI: 1.11-2.15), Myanmar (AOR: 1.74; 95% CI: 1.02-2.95)], respondent's older age (in Bangladesh, Nepal, and Myanmar), child's older age (in Pakistan and Myanmar), and middle and rich groups of wealth-index (in Bangladesh and Pakistan) were strong risk factors for DBMHL. On the other hand, female child [Nepal (AOR: 0.50; 95% CI: 0.26-0.95), Pakistan (AOR: 0.58; 95% CI: 0.41-0.84)], higher education [in Pakistan], respondent not participated in decision making [in Bangladesh and Nepal] and media access [Nepal (AOR: 0.44; 95% CI: 0.20-0.98)] had negative association with DBMHL.

CONCLUSION

The DBMHL persists in all selected countries, with a higher prevalence in urban areas than in rural areas. In order to control the higher prevalence of DBMHL in urban areas, respective countries need urgent implementation of multisectoral actions through effective policies and empowering local communities.

Intra-household double burden of malnutrition in a North African nutrition transition context: magnitude and associated factors of child anaemia with mother excess adiposity

Objective

In the Middle East and North Africa region, the nutrition transition has resulted in drastic increases in excess adiposity, particularly among women, while some types of undernutrition remain prevalent, especially among pre-school children. We assessed the magnitude, nature and associated factors of the within-household co-occurrence of anaemia in children and excess adiposity in mothers.

Design

Cross-sectional survey using stratified two-stage random cluster sampling to survey households with women aged 20–49 years. BMI≥25·0 kg/m2 defined overweight and BMI≥30·0 kg/m2 obesity, while anaemia for children was defined as Hb<110 g/l. The associations between child anaemia and mother excess adiposity, and sociodemographic and lifestyle factors were estimated by multinomial regression.

Setting

Greater Tunis area, Tunisia, in 2009–2010.

Subjects

Children aged 6–59 months living with their 20–49-year-old mothers (437 child–mother pairs).

Results

The most prevalent double burden of malnutrition in child–mother pairs by far was the anaemic child and overweight mother (24·4 %; 95 % CI 20·1, 29·3 %). A significant proportion of pairs were anaemic child and obese mother (14·4 %; 95 % CI 11·0, 18·5 %). The co-occurrence of anaemia in child and excess adiposity in mother was neither synergetic nor antagonistic (P=0·59 and 0·40 for anaemia–overweight and anaemia–obesity, respectively). This double burden was more frequent among child–mother pairs with younger children, with mothers of higher parity and higher energy intakes.

Conclusions

The high prevalence of anaemic child and overweight or obese mother requires special attention e.g. through interventions which simultaneously target both types of malnutrition within the same household.

Associations of stunting at 2 years with body composition and blood pressure at 8 years of age: longitudinal cohort analysis from lowland Nepal

BACKGROUND

Stunting remains a very common form of child malnutrition worldwide, particularly in South Asian populations. There is poor understanding of how it develops and how it is associated with subsequent phenotype.

SUBJECTS/METHODS

We used data from a longitudinal cohort of children (n = 841) in lowland Nepal to investigate associations of stunting at 2 years with maternal traits and early growth patterns, and with body size and composition, kidney dimensions by ultrasound, lung function by spirometry and blood pressure (BP) at 8 years.

RESULTS

Compared to non-stunted children, children stunted at 2 years came from poorer families and had shorter, lighter mothers. They tended to have higher birth order, were born smaller, and remained shorter, lighter and thinner at 8 years. They had lower leg length, lean and fat masses, smaller kidneys, and reduced lung function (all p < 0.0001). These differences persisted with smaller magnitude after adjusting for current height, maternal height and education, family assets and birth order. Stunting was not associated with BP.

DISCUSSION

Stunting developed on an inter-generational timescale in this population and its risk increased with birth order. At 8 years, children stunted at 2 years had deficits in tissue masses and some aspects of physical function that were only partially attributable to their persisting short height and maternal phenotype. This suggests that the early stunting is associated with greater deficits in long-term outcomes than would be expected from the persistent short stature alone.

Child Nutritional Status in the Changing Socioeconomic Region of the Northern Amazon, Brazil

The living conditions (i.e., socioeconomic, healthcare-related, nutritional, and environmental) to which children are exposed may influence their ability to reach their optimal growth potential. This review focuses on the relationship between the nutritional status of children under five years of age and social and environmental factors in Northern Brazil. Children living in this region have limited access to healthcare and face precarious socioeconomic and environmental conditions. This analysis was based on data from national health surveys, the consolidated food, nutrition surveillance system (SISVAN), and indicators of the DPSEEA (driving force, pressure, state, exposures, health effects, and actions) framework. The northern region has the worst living conditions in the country, and children under five years of age have significant height-for-age, weight-for-age, and weight-for-height deficits. Concomitantly, the prevalence of children who are overweight has increased significantly, although it remains lower than that in more developed Brazilian regions. Insufficient and/or inadequate dietary practices and early exposure to unfavorable living conditions are risk factors for nutritional deviations. Further advances in public health policies that consider regional characteristics, particularly in the north, where progress has been slower, are needed.

Prevalence and determinants of stunting in a conflict-ridden border region in Armenia - a cross-sectional study

BACKGROUND

Despite global efforts, stunting remains a public health problem in several developing countries. The prevalence of stunting among 0- to 5-year-old children in Armenia has increased from 17% in 2000 to 19% in 2010. A baseline study was conducted among preschool children in Berd, a region near the northeastern border of Armenia that has experienced intermittent military tension for over 20 years.

METHODS

We conducted a cross-sectional study including 594 children aged 6-month- 6 years old and their caregivers in our analysis, to assess the prevalence and determinants of stunting. We calculated the anthropometric measurements and hemoglobin levels of children; analyzed children's stool and conducted a survey with children's caregivers. We employed the hierarchical logistic regression model to explore the predictors of stunting among 25-72 months old children and multivariable logistic regression models to investigate the predictors of stunting among 6-24 months old children. Individual and residence level variables were included in the models including anemia, minimum dietary diversity, mothers' height, the overall duration of breastfeeding, birthweight, child's history of diarrhea and mean socio-economic score.

RESULTS

The prevalence of stunting was significantly higher among the 6-24 months old children (13.3%) compared to the children aged 25-72 months old (7.8%). We did not find any differences in the prevalence of stunting by place of residence in either age group. The 6-24 months old children who consumed at least four food groups during the previous day (minimum dietary diversity) had 72% lower odds of being stunted (p < 0.05). Each kilogram increase in birthweight was associated with 76% lower odds of being stunted (OR = 0.24, p < 0.01). Mother's height significantly decreased the odds of stunting among the children 25-72- months old (OR = 0.86, p < 0.001). BMI was also a significant predictor of stunting among both age-groups.

CONCLUSIONS

The study results highlight the significance of mother's height, birthweight, and adequate complementary feeding to reduce stunting. Further studies are needed to determine the possible association of anemia and stunting with the ongoing conflict in the region, as well as socioeconomic conditions and food insecurity in the region.