Differences in risk factors associated with single and multiple concurrent forms of undernutrition (stunting, wasting or underweight) among children under 5 in Bangladesh: a nationally representative cross-sectional study

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Abstract

Objectives

The study aims to differentiate the risk factors of single and multiple concurrent forms of undernutrition among children under 5 in Bangladesh.

Design

A nationally representative cross-sectional study.

Setting

Bangladesh.

Respondents

Children age under 5 years of age.

Outcome measure

This study considered two dichotomous outcomes: single form (children without single form and with single form) and multiple concurrent forms (children without multiple forms and with multiple forms) of undernutrition.

Statistical analysis

Adjusted OR (AOR) and CI of potential risk factors were calculated using logistic regression analysis.

Results

Around 38.2% of children under 5 in Bangladesh are suffering from undernutrition. The prevalence of multiple concurrent forms and single form of child undernutrition was 19.3% and 18.9%, respectively. The key risk factors of multiple concurrent forms of undernutrition were children born with low birth weight (AOR 3.76, 95% CI 2.78 to 5.10); children in the age group 24–35 months (AOR 2.70, 95% CI 2.20 to 3.30) and in the lowest socioeconomic quintile (AOR 2.57, 95% CI 2.05 to 3.23). In contrast, those children in the age group 24–35 months (AOR 1.94, 95% CI 1.61 to 2.34), in the lowest socioeconomic quintile (AOR 1.79, 95% CI 1.45 to 2.21) and born with low birth weight (AOR 1.52, 95% CI 1.11 to 2.08) were significantly associated with a single form of undernutrition. Parental education, father’s occupation, children’s age and birth order were the differentiating risk factors for multiple concurrent forms and single form of undernutrition.

Conclusion

One-fifth of children under 5 years of age are suffering multiple concurrent forms of undernutrition, which is similar to the numbers suffering the single form. Parental education, father’s occupation, children’s age and birth order disproportionately affect the multiple concurrent forms and single form of undernutrition, which should be considered to formulate an evidence-based strategy for reducing undernutrition among these children.

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Most cited references 44

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The effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries.

Christine M McDonald, Ibironke Olofin, Seth Flaxman … (2013)

Child stunting, wasting, and underweight have been individually associated with increased mortality. However, there has not been an analysis of the mortality risk associated with multiple anthropometric deficits. The objective was to quantify the association between combinations of stunting, wasting, and underweight and mortality among children <5 y of age. We analyzed data from 10 cohort studies or randomized trials in low- and middle-income countries in Africa, Asia, and Latin America with 53,767 participants and 1306 deaths. Height-for-age, weight-for-height, and weight-for-age were calculated by using the 2006 WHO growth standards, and children were classified into 7 mutually exclusive combinations: no deficits; stunted only; wasted only; underweight only; stunted and underweight but not wasted; wasted and underweight but not stunted; and stunted, wasted, and underweight (deficit defined as < -2 z scores). We calculated study-specific mortality HRs using Cox proportional hazards models and used a random-effects model to pool HRs across studies. The risk of all-cause mortality was elevated among children with 1, 2, and 3 anthropometric deficits. In comparison with children with no deficits, the mortality HRs were 3.4 (95% CI: 2.6, 4.3) among children who were stunted and underweight but not wasted; 4.7 (95% CI: 3.1, 7.1) in those who were wasted and underweight but not stunted; and 12.3 (95% CI: 7.7, 19.6) in those who were stunted, wasted, and underweight. Children with multiple deficits are at a heightened risk of mortality and may benefit most from nutrition and other child survival interventions.

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Wasting and stunting--similarities and differences: policy and programmatic implications.

André Briend, Tanya Khara, Carmel Dolan (2015)

Wasting and stunting are often presented as two separate forms of malnutrition requiring different interventions for prevention and/or treatment. These two forms of malnutrition, however, are closely related and often occur together in the same populations and often in the same children. Wasting and stunting are both associated with increased mortality, especially when both are present in the same child. A better understanding of the pathophysiology of these two different forms of malnutrition is needed to design efficient programs. A greatly reduced muscle mass is characteristic of severe wasting, but there is indirect evidence that it also occurs in stunting. A reduced muscle mass increases the risk of death during infections and also in many other different pathological situations. Reduced muscle mass may represent a common mechanism linking wasting and stunting with increased mortality. This suggests that to decrease malnutrition-related mortality, interventions should aim at preventing both wasting and stunting, which often share common causes. Also, this suggests that treatment interventions should focus on children who are both wasted and stunted and therefore have the greatest deficits in muscle mass, instead of focusing on one or the other form of malnutrition. Interventions should also focus on young infants and children, who have a low muscle mass in relation to body weight to start with. Using mid-upper-arm circumference (MUAC) to select children in need of treatment may represent a simple way to target young wasted and stunted children efficiently in situations where these two conditions are present. Wasting is also associated with decreased fat mass. A decreased fat mass is frequent but inconsistent in stunting. Fat secretes multiple hormones, including leptin, which may have a stimulating effect on the immune system. Depressed immunity resulting from low fat stores may also contribute to the increased mortality observed in wasting. This may represent another common mechanism linking wasting and stunting with increased mortality in situations where stunting is associated with reduced fat mass. Leptin may also have an effect on bone growth. This may explain why wasted children with low fat stores have reduced linear growth when their weight-for-height remains low. It may also explain the frequent association of stunting with previous episodes of wasting. Stunting, however, can occur in the absence of wasting and even in overweight children. Thus, food supplementation should be used with caution in populations where stunting is not associated with wasting and low fat stores.

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The relationship between wasting and stunting: a retrospective cohort analysis of longitudinal data in Gambian children from 1976 to 2016

Simon M. Schoenbuchner, Carmel Dolan, Martha Mwangome … (2019)

ABSTRACT Background The etiologic relationship between wasting and stunting is poorly understood, largely because of a lack of high-quality longitudinal data from children at risk of undernutrition. Objectives The aim of this study was to describe the interrelationships between wasting and stunting in children aged <2 y. Methods This study involved a retrospective cohort analysis, based on growth-monitoring records spanning 4 decades from clinics in rural Gambia. Anthropometric data collected at scheduled infant welfare clinics were converted to z scores, comprising 64,342 observations on 5160 subjects (median: 12 observations per individual). Children were defined as “wasted” if they had a weight-for-length z score <–2 against the WHO reference and “stunted” if they had a length-for-age z score <–2. Results Levels of wasting and stunting were high in this population, peaking at approximately (girls–boys) 12–18% at 10–12 months (wasted) and 37–39% at 24 mo of age (stunted). Infants born at the start of the annual wet season (July–October) showed early growth faltering in weight-for-length z score, putting them at increased risk of subsequent stunting. Using time-lagged observations, being wasted was predictive of stunting (OR: 3.2; 95% CI: 2.7, 3.9), even after accounting for current stunting. Boys were more likely to be wasted, stunted, and concurrently wasted and stunted than girls, as well as being more susceptible to seasonally driven growth deficits. Conclusions We provide evidence that stunting is in part a biological response to previous episodes of being wasted. This finding suggests that stunting may represent a deleterious form of adaptation to more overt undernutrition (wasting). This is important from a policy perspective as it suggests we are failing to recognize the importance of wasting simply because it tends to be more acute and treatable. These data suggest that stunted children are not just short children but are children who earlier were more seriously malnourished and who are survivors of a composite process.

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Author and article information

Journal

Journal ID (nlm-ta): BMJ Open

Journal ID (iso-abbrev): BMJ Open

Journal ID (hwp): bmjopen

Journal ID (publisher-id): bmjopen

Title: BMJ Open

Publisher: BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )

ISSN (Electronic): 2044-6055

Publication date Collection: 2021

Publication date (Electronic): 13 December 2021

Volume: 11

Issue: 12

Electronic Location Identifier: e052814

Affiliations

[1 ]departmentDepartment of Public Health , First Capital University of Bangladesh , Chuadanga, Bangladesh

[2 ]departmentCollege of Nursing, Midwifery and Healthcare , University of West London , Brentford, London, UK

[3 ]departmentDepartment of Public Health and Sports Sciences , University of Gävle , Gavle, Gävleborg, Sweden

[4 ]departmentSchool of Allied Health, Faculty of Health, Education, Medicine, and Social Care , Anglia Ruskin University , Chelmsford, London, UK

[5 ]departmentInstitute of Environmental Medicine , Karolinska Institutet , Stockholm, Sweden

Author notes

[Correspondence to ] Dr Manzur Kader; manzur.kader@ 123456ki.se

Author information

Hafiz T A Khan http://orcid.org/0000-0002-1817-3730

Manzur Kader http://orcid.org/0000-0001-8181-648X

Article

Publisher ID: bmjopen-2021-052814

DOI: 10.1136/bmjopen-2021-052814

PMC ID: 8672009

PubMed ID: 34903543

SO-VID: eb60a8e9-cfdf-433a-bc04-325135e45bcd

License:

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

History

Date received : 27 April 2021

Date accepted : 12 November 2021

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ScienceOpen disciplines: Medicine

Keywords: community child health,nutrition & dietetics,public health,preventive medicine

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ScienceOpen disciplines: Medicine

Keywords: community child health, nutrition & dietetics, public health, preventive medicine

Differences in risk factors associated with single and multiple concurrent forms of undernutrition (stunting, wasting or underweight) among children under 5 in Bangladesh: a nationally representative cross-sectional study

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Abstract

Objectives

Design

Setting

Respondents

Outcome measure

Statistical analysis

Results

Conclusion

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China Tropical Medicine

Most cited references 44

The effect of multiple anthropometric deficits on child mortality: meta-analysis of individual data in 10 prospective studies from developing countries.

Wasting and stunting--similarities and differences: policy and programmatic implications.

The relationship between wasting and stunting: a retrospective cohort analysis of longitudinal data in Gambian children from 1976 to 2016

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