NUTRITIONAL STATUS OF UNDER-5 CHILDREN IN BANGLADESH

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1 South Asian Journal of Population and Health 2(1) 2009, 1-11 NUTRITIONAL STATUS OF UNDER-5 CHILDREN IN BANGLADESH AZIZUR RAHMAN 1 and SOMA CHOWDHURY BISWAS 2 Abstract Protein Energy Malnutrition (PEM) is a major health problem in Bangladesh and it affects the physical growth and logical development of children. Data from the Bangladesh Demographic and Health Survey (BDHS) was used in this study to explore nutritional status of children aged 0-59 months. The prevalence of malnutrition is assessed by three standard anthropometric indicators: underweight, stunting and wasting, following the WHO guidelines and cut-off points. The distributions of Z-scores for the study children showed considerably far downward distributions for all indicators from the reference population mean zero. In addition, total stunting, wasting and underweight were observed in 44%, 10% and 47% (among them 18%, 1% and 13% were severely stunted, wasted and underweight) of the children respectively and the trends in prevalence of malnutrition are increasing after the BDHS. The study points out that, malnutrition is one of the most critical components for child health that affects almost 56.5% Bangladeshi children. Reassessment of current policies and further appropriate interventions should be formulated to improve socioeconomic and maternal conditions to reduce the overall burden of malnutrition. Key words: PEM, Z-score, WHO, Malnutrition Introduction Child nutrition status is an important measure of poverty in a population; and poverty, malnutrition and disease are interlinked with each other. Malnutrition in children is the consequence of a range of factors, which are often related to poor food quality, insufficient food intake, and severe and repeated infectious diseases; or frequently it involves some combination of the three (de Onis et al., 1993). These conditions, in turn, are closely linked to the overall standard of living and whether a population can meet its basic needs, such as access to food, housing and health care (WHO, 1997). Therefore, child nutritional status assessment not only serves as a means for evaluating the health condition and survival of children but also provides an indirect measurement of the quality of life of an entire population. According to WHO (1997), malnutrition is synonymous with protein-energymalnutrition (PEM) signifying an imbalance between the supply of protein and energy and the body s demand for them to ensure optimal growth and function. This 1 National Centre for Social and Economic Modelling, University of Canberra, ACT 2601 Australia, Azizur.Rahman@natsem.canberra.edu.au 2 Department of Statistics, University of Chittagong, Chittagong-4331, Bangladesh, soma_chow@hotmail.com

2 2 Rahman & Biswas imbalance of protein and energy intake leads to malnutrition in the form of stunting, wasting and underweight. In practice, stunting is defined as a height-for-age measurement of below minus two-standard deviation of the median National Centre for Health Statistics (NCHS) reference values, and is generally considered a marker of chronic malnutrition (Mitra et al., 2001). By contrast, acute malnutrition, termed as wasting is defined by a weight-for-height indicator. In addition, a composite form of malnutrition, known as underweight or under-nutrition is defined with a weightfor-age indicator. Each kind of malnutrition can be classified as - severe and moderate levels according to the cut-off points. However, as different forms of malnutrition have different causes and consequences and require substantially different treatments, a clear and appropriate nomenclature to differentiate them is needed (Collins et al., 2006). Although an inverse relationship exists between anthropometric indicators of nutritional status and mortality, several studies have documented that severely malnourished children are at a much greater risk of dying than others (Gomez et al., 1956; Schofield and Ashworth, 1996). But, an elevated risk of mortality has also been observed by Pelletier (1994) for children at moderate level of malnutrition. When considering the relative proportions of severe versus moderate malnutrition in populations, authors revealed that the majority of nutrition related deaths were significantly associated with moderate level, rather than severe level, malnutrition. For instance, moderate wasting is associated with a mortality rate of per 1000 children per year (Chen et al., 1980; Pelletier, 1994) and severe wasting is associated with a mortality rate of per 1000 children per year (Pelletier, 1994). This equates to over 1 5 million child deaths associated with severe wasting and 3 5 million with moderate wasting every year. Therefore, information for both severe and moderate levels of malnutrition is important for policy makers to develop strategies to reduce the overall burden of malnutrition. Bangladesh, a very densely populated country, is one of the poorest developing countries in the world; more than three-fifths of its population are living below the poverty line. As a result of overcrowding, unemployment, poverty and poor access to adequate food as well as health services, infectious diseases and malnutrition are common in this society. It is noted that, increased morbidity among children living in poverty is strongly linked to malnutrition and an inadequate diet. PEM leads to disturbance in growth and increases morbidity and mortality rate and also decreases psychological and intellectual development (Pollitt et al., 1993). Researchers have revealed that malnutrition leads to more severe infection and higher case fatality in Bangladeshi children (Black et al., 1984), and it is one of their major causes of morbidity and mortality (Alam et al., 1989; Bairagi and Chowdhury, 1994). The government of Bangladesh, UNICEF, and the World Bank are collaborating to launch major projects designed to improve nutrition status of the nation and reduce

3 Nutritional Status of under-5 Children in Bangladesh 3 childhood morbidity and mortality. The objectives of this study are to explore the levels and trends in malnutrition of Bangladeshi children aged under-5 years and reveal their overall nutritional status using a comparison between anthropometric health indicators. This information should help to reassess the current policies of child development and plan for significant new interventions to assist the better health of these children. Materials and Methods A nationally representative survey, the Bangladesh Demographic and Health Survey (BDHS), was used in this study. The survey has collected data during the period early November 1999 to mid March 2000 as a part of the worldwide Demographic and Health Surveys program, which is designed to collect information on fertility, family planning, infant and child mortality, maternal and child health, and knowledge of AIDS. A two-stage probability sample of 10,544 ever-married women below age 50 years were interviewed, providing a complete birth history for all live births. Moreover, in-depth information, such as detailed information on breast-feeding practices, immunization practices were available for each live birth that occurred during a 5-year period before the interview date. For anthropometric data, all living children aged up to five years and their mothers were eligible for height and weight measurement. About eighty four percent of 6,430 eligible children under-5 years were weighed and measured. A total sample of 5,333 children was recruited for this study whose anthropometric measurements were provided. Details of the survey methodology, sample and the principal findings have been published elsewhere (Mitra et al., 2001). Three standard indices of physical growth that describe the nutritional status of children were considered for the anthropometric analyses, those were Weight-for-age (underweight), Height-for-age (stunting) and Weight-for-height (wasting). Each of these indices is expressed in terms of the number of standard deviation units (Zscore) from the median of the NCHS/WHO international reference population and provides somewhat different information about the nutritional status of children. A drop in wasting reflects an acute problem; that is, one that occurred recently. A drop in stunting signals a chronic problem, one that has persisted for several months, but is not necessarily present when the measurement is taken. A decline in underweight may be connected with one or both of the above-mentioned explanations, since it expresses an overall situation (Rahman, 2002). The report of WHO working group (1986) on measuring nutritional status of children recommended the use of Z-scores as it has some important advantages over other measures. According to this recommendation, the prevalence of malnutrition can be calculated on the basis of the proportion of individuals in the observed population whose index

4 4 Rahman & Biswas is below minus 2 standard deviation of the index for the reference population. The total prevalence of malnutrition can be classified as severe and moderate if children with Z-scores below minus 3 standard deviations (-3SD) and children with Z-scores between minus 3 standard deviations (-3SD) and below minus 2 standard deviation (- 2SD) from the median of the NCHS reference population respectively (Mitra et al., 2001; Rahman and Chowdhury, 2007). Thus, for analytic purposes, this study used those cut-off points recommended by WHO for defining malnutrition. The general approach adopted in the analysis is to differentiate among children who were relatively well-nourished (Z-scores >= -2SD), those who were moderately malnourished (-3SD <= Z-scores < -2SD) and those who were severely malnourished (Z-scores < -3SD). Results The distributions of Z-scores for different health indicators of under-5 children in Bangladesh are presented in figure 1. All three Z-scores based indicators appear to be distributed normally with the mean values located to the far left of the WHO/NCHS reference mean zero. Frequency of children Height-for-age Weight-for age Weight-for-height Z-scores Fig. 1: Z-scores distributions of different health indicators The Height-for-age indicator has relatively wide distribution around the mean value and higher standard deviation 1.4 compared to other indices. The distribution of weight-for-age criterion has mean and standard deviation However, the weight-for-height Z-scores distribution shows a high density around the mean value

5 Nutritional Status of under-5 Children in Bangladesh 5 (-0.94) with a standard deviation (0.93) very close to the NCHS reference population standard deviation (SD). The mean values of Z-scores for height-for-age and weightfor-age indices are found to be slightly higher than -2 Z-score with high standard deviations. Therefore, average value of Z-scores for Bangladeshi children is nearly 2 Z-score below the reference population mean value zero. Table 1 shows nutritional status of children by three anthropometric indicators: stunting, wasting and underweight. Results reveal that nearly half of the preschool children in Bangladesh are living with underweight and one in three children (34%) is moderately undernourished. The prevalence of stunting in children was 44%, of whom 18% were observed to be severely stunted. Moreover, although 90% children were free from acute malnutrition, 1% and 9% children were severely and moderately wasted, respectively which add up the total prevalence of wasting in the high severity prevalence percentage range (WHO, 1995). Table 1: Nutritional status of children in Bangladesh, BDHS a Nutritional Status Indicators Malnutrition Severe Moderate Total Well nourished Stunting Wasting Underweight a Figures are in percentage Trends in different levels of malnutrition for Bangladeshi children aged 0-59 months are presented in graphs 2-4. Statistics of year are considered from the report of BDHS (BDHS, 2004). The level of severe stunting has decreased dramatically by 10% between the and BDHSs and then only 1% during next three years. However, the moderate stunting rate declined by only 1% during these time periods. Both the levels of severe and moderate wasting declined somewhat rapidly between the first two surveys (in fig. 3). Additionally, between the and surveys, the prevalence of severe wasting was unchanged but the rate of moderate wasting increased by about 2%. By contrast, the level of moderate underweight was the lowest in the survey (34%) and the prevalence rate of severe underweight decreased by about 8%, from about 21% in to 13% in , and then remained unchanged to the BDHS. Figure 5 shows the trend in total prevalence of malnutrition by different health indicators. The bar graph reveals that only the prevalence of stunting has declined, i.e., the total prevalence of stunting decreased by 12%, from 55% in to 44%

6 6 Rahman & Biswas in , and then to 43% in BDHS; and the most marked decline in the prevalence of severe stunting was within the survey (see, fig. 2). The other two forms of malnutrition, underweight and wasting, show fluctuating trends with the lowest prevalence rates in the BDHS. Stunting (% ) Severe Moderate Year Wasting (% ) Severe Moderate Year Fig.2 Fig.3 Underweight (% ) Severe Moderate Year Fig.4 Children (% ) Underweight Stunting Types of Malnutrition Fig.5 Wasting The selected overall nutritional status of Bangladeshi children is presented in diagram 6. Almost 30% children are stunted and underweight, more than 5% of children are in an extremely malnourished condition i.e., they undergo all three forms of malnutrition, that is underweight, stunted and wasted. There is no child that both stunted and wasted because of the fact that wasting signals an acute growth disturbance that has occurred recently whereas stunting signals a chronic problem that has occurred over several months. Nearly 8% of children are underweight only,

7 Nutritional Status of under-5 Children in Bangladesh 7 which is 1% less and 7% more than the percentages of children stunted only and wasted only respectively. Moreover, about 44% children are free from protein-energy malnutrition which indicates that more than half of the children consistently failed to receive proper nutrition, identifying a serious public health problem in the country. Discussion Fig. 6: Selected overall nutritional status of children in Bangladesh, The World Health Organization working group s report on measuring the nutritional status of children recommends the use of Z-scores system as they have significant advantages over other approaches. In brief, Z-scores indices are linear, sex independent and allow for further computation of summary statistics such as means and standard deviations to directly classify a population s nutritional status (Rahman and Chowdhury, 2007). For instance, an average value of Z-scores significantly lower than the mean value zero of the reference distribution typically means that the entire distribution of the study objects has shifted downward, suggesting that most, if not all, individuals have been affected. The findings of this study show that the average values of Z-scores for all indices are considerably lower than zero - especially for the average values of height-for-age and weight-for-age indicators and their distributions are shifted far to the left side. The distribution of Z-scores may vindicate the severity of health and nutrition condition within the entire community instead of only malnourished group according to the cut-off points (Yip and Scalon, 1994). Moreover, the observed standard deviation value of the Z-scores distribution is very useful for assessing data quality. With accurate anthropometric measurements

8 8 Rahman & Biswas and age assessment, the SDs of the observed height-for-age, weight-for-height, and weight-for-age Z-scores distributions should be relatively constant and close to the expected value of 1 for the reference distribution. Any observed standard deviation for a Z-scores distribution above 1.3 suggests inaccurate data due to measurement error or incorrect age reporting (WHO, 1997). The observed SD of 1.4 for the heightfor-age index in this study may hint errors in measurement of height or incorrect age reporting in the survey data. Therefore, the distribution of Z-scores not only predicts the severity of health and nutritional problems, requiring an increased awareness and intervention for the community, but is also useful to assess the data quality of a survey. This study provides further insight into the nutritional status of children, generally categorised as protein-energy malnutrition and good health, by redefining malnutrition into different forms and levels according to different anthropometric indicators, stunting, wasting and underweight. It is noted that "stunting" indicates reduced linear growth compared to the expected growth in a child of the same age, and reflects a chronic form of malnutrition with failure to receive adequate nutrition over a long period, that may be also caused by recurrent and chronic illness; wasting means a deficit body weight compared to the expected weight for the same height, and reflects an acute form of malnutrition that has association with inadequate food intake over a short period or recent episodes of illness; and underweight indicates a deficit in body weight compared to expected weight for the same age and hight, and signifies a complex form of malnutrition which takes into account both the chronic and acute forms of malnutrition (Rahman, 2002). In addition, each form of malnutrition can be classified as severe and moderate based on the cut-off points (Mitra et al., 2001). As different forms as well as levels of malnutrition have different causes and consequences, they require substantially different treatments, and hence a clear and appropriate nomenclature to differentiate them is needed (Collins et al., 2006). The results revealed that the total prevalence of stunting, wasting and underweight were 44%, 10% and 47% respectively, of which 26%, 9% and 34% of children were moderately stunted, wasted and underweight respectively. These findings indicate that the severity of stunting and underweight are within a very high range and wasting has a high prevalence rate according to WHO-classification (Gorstein et al., 1994; WHO, 1997), which confirm malnutrition is a serious public health problem. Moreover, studies in Bangladesh reveal that a set of factors are significantly associated with different levels of malnutrition assessed by different indicators (Rahman, 2002; Rahman and Chowdhury, 2007), and that demographic characteristics appeared to be the most significant factors for stunting (Rahman and Chowdhury, 2007). A high prevalence of stunting is generally associated with low

9 Nutritional Status of under-5 Children in Bangladesh 9 socioeconomic status (Gorstein et al., 1994; Rahman and Chowdhury, 2007), and poor maternal health and lower birth size (Rahman and Chowdhury, 2007). Hence, intervention may focus on those factors to improve the nutritional status of children. Trends in severe and moderate levels of malnutrition revealed that between the and BDHSs, the prevalence of severe malnutrition accessed by all three indicators, has rapidly declined, and after this period the prevalence rates remained unchanged. The prevalence of moderate level malnutrition showed significant change only in wasting. A rapid drop was observed in prevalence rate of moderate wasting between the and BDHSs and then a dramatic increase in the BDHS. Although the total prevalence rate of stunting was stable around 44% after BDHS, the total prevalence rates of wasting and underweight are increasing. There are reasons for this increasing trend in wasting and underweight and this issue requires more attention to evaluate the current child development programmes and to develop significant future interventions. The findings of the selected overall nutritional condition of Bangladeshi children assessed by a combination of the three indicators, show that one of three Bangladeshi children are in a stunted and underweight condition; more than 5% are in an extremely deficient nutrition condition i.e. they have all three kinds of malnutrition, underweight, stunting and wasting. In addition, there is no child that is both stunted and wasted as wasting signals an acute growth disturbance that has occurred recently whereas stunting signals a chronic problem that has occurred over several months. Keller and Fillmore (1983) have shown that these two indicators are independent, and measure completely different nutritional conditions. Use of weight-for-age criteria cannot distinguish acute malnutrition from chronic malnutrition (Waterlow et al., 1977). This analysis suggests that more than half of the children consistently failed to receive proper nutrition. Of these, 5.3% of children had very severe starvation, identifying a serious public health problem in Bangladesh. In conclusion, the distributions of Z-scores for the study children show considerable downward distributions for all indicators from the reference population. About 44%, 10% and 47% Bangladeshi pre-school children are stunted, wasted and underweight respectively. This signifies a very high severity levels in different forms of malnutrition. Moreover, trends between the and BDHSs show the prevalence of malnutrition is increasing. This study reveals that the overall nutritional status of Bangladeshi children is very poor and more than 56% pre-school children in this country are in some form of malnutrition. Therefore, policy makers should be concerned about the high prevalence of severe and moderate malnutrition and its recent increasing trends. This knowledge can be used to assess the function of running child development programmes and plan for future interventions to improve the overall nutritional status of children.

10 10 Rahman & Biswas Acknowledgments The authors are grateful to Professor S. Ahmed and Drs D. Hossain and C. Matthews for their insightful comments in reviewing the earlier version of the manuscript. References Alam, N., Wojtyniak, B. and Mohammed M. Rahaman (1989). Anthropometric Indicators and Risk of Death, American Journal of Clinical Nutrition 49(5): Bairagi R. and Mridul K. Chowdhury (1994). Socioeconomic and Anthropometric Status, and Mortality of Young Children in Rural Bangladesh, International Journal of Epidemiology 23(6): BDHS (2004). Bangladesh Demographic and Health Survey , Dhaka: NIPORT and Mitra &Associates. Black, Robert E., Brown, Kenneth H. and S. Becker (1984). Malnutrition is a Determining Factor in Diarrheal Duration, but not Incidence, among Young Children in a Longitudinal Study in Rural Bangladesh, American Journal of Clinical Nutrition 37(1): Chen, Lincoln C., Chowdhury, Alauddin K.M.A. and Sandra L. Huffman (1980). Anthropometric Assessment of Energy-Protein Malnutrition and Subsequent Risk of Mortality among Preschool Aged Children, American Journal of Clinical Nutrition 33(8): Collins, S., Dent, N., Binns, P., Bahwere, P., Sadler, K. and A. Hallam (2006). Management of Severe Acute Malnutrition in Children, Lancet 368(9551): deonis, M., Monteiro, C., Akre J. and G. Clugston (1993). The Worldwide Magnitude of Protein- Energy Malnutrition: An Overview from the WHO Global Database on Child Growth, Bulletin of the World Health Organization 71(6): Gomez, P., Galvan, Ramos R., Frenk, S., Munoz, Cravioto J., Chavez, R. and J. Vazquez (1956). Mortality in Second and Third Degree Malnutrition, Journal of Tropical Paediatrics 2(2): Gorstein, J., Sullivan, K., Yip, R., deonis, M., Trowbridge, F., Fajans, P. and G. Clugston (1994). Issues in the Assessment of Nutritional Status Using Anthropometry, Bulletin of the World Health Organization 72(2): Keller, W. and M. Fillmore (1983). Prevalence of Protein-Energy Malnutrition, World Health Statistics Quarter 36: Mitra, Satindra N., Al-Sabir, A., Saha, T. and S. Kumar (2001). Bangladesh Demographic and Health Survey , Dhaka: NIPORT and Mitra & Associates. Pelletier, David L. (1994). The Relationship Between Child Anthropometry and Mortality in Developing Countries: Implications for Policy, Programs and Future Research, Journal of Nutrition 124(10 Suppl): 2047S-2081S. Pollitt, E., Gorman, Kathleen S., Engle, Patrice L., Martorell, R. and Juan A. Rivera (1993). Early Supplementary Feeding and Cognition: Effects Over two Decades, Monograph of Social Research: Child Development 58(7): 1-99.

11 Nutritional Status of under-5 Children in Bangladesh 11 Rahman, A. (2002). Factors Associated with Nutritional Status of Children in Bangladesh: Levels, Patterns and Determinants, Unpublished M.Sc. thesis, Department of Statistics, University of Chittagong, Chittagong. Rahman, A. and S. Chowdhury (2007). Determinants of Chronic Malnutrition among Pre-school Children in Bangladesh, Journal of Biosocial Science 39(2): Schofield, C. and A. Ashworth (1996). Why have Mortality Rates for Severe Malnutrition Remained so High?, Bulletin of the World Health Organization 74(2): Waterlow, John C., Buzina, R., Keller, W., Lane, Michael J., Nichaman, Milton Z. and James M. Tanner (1977). The Presentation and Use of Height and Weight data for Comparing the Nutritional Status of Groups of Children Under the Age of 10 Years, Bulletin of the World Health Organization 55(4): WHO (1986). Use and Interpretation of Anthropometric Indicators of Nutritional Status, Bulletin of the World Health Organization 64(6): WHO (1995). Physical Status: The Use and Interpretation of Anthropometry, Report of a WHO Expert Committee, Technical report series 854: WHO (1997). WHO Global Database on Child Growth and Malnutrition, Geneva: World Health Organization. World Bank (2002). Poverty in Bangladesh: Building on Progress, Poverty Reduction and Economic Management Sector Unit, South Asia Region: The World Bank - Report no BD: Yip, R. and K. Scalon (1994). The Burden of Malnutrition: A Population Perspective, Journal of Nutrition 124(10 Suppl): 2043S-2046S.

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