RESEARCH BRIEF Determinants of Under Nutrition in Children under 2 years of age from Rural Bangladesh AM SHAMSIR AHMED, TAHMEED AHMED, SK ROY, NURUL ALAM AND MD IQBAL HOSSAIN From the Centre for Nutrition and Food Security, International Centre for Diarrheal Disease Research, Bangladesh. Correspondence to: Dr Tahmeed Ahmed, Director and Senior Scientist, Centre for Nutrition and Food Security, ICDDR, B, GPO Box 128, Dhaka, Bangladesh. tahmeed@icddrb.org Received: September 27, 2011; Initial review: November 08, 2011; Accepted: April 10, 2012. PII: S097475591100803 2
ABSTRACT This study aimed to assess the determinants of under nutrition among under-two year old children of rural Bangladesh. The data of the National Nutrition Program baseline survey conducted in 2004 was analyzed, which included 8,885 under-two children and their mothers. Among the children studied, 41%, 35% and 18% were stunted, underweight, and wasted; and 16%, 11.5% and 3% were severely-stunted, - underweight, and wasted, respectively. Multivariate analysis revealed that undernourished children were less likely to be female and having received measles vaccination, more likely to have suffered from diarrhea in the previous two weeks, and more likely to have older- (>30 years), shorter- (<145 cm), undernourished- (BMI 18.5 kg/m 2 ) and illiterate/less educated mother. Children with moderate stunting and underweight were more likely to reside in households with un-hygienic toilet. Children with all forms of under nutrition were more often from families with lowest quintile of asset index. The identified associated/risk factors can be used for designing and targeting preventive programs for undernutrition. Key words: Bangladesh, Children, Risk factors, Undernutrition. One fifth of all under-five year old children in the developing world are malnourished and it is associated with more than one-third of all under-five deaths globally [1]. From the latest national survey (BDHS 2007), 43% of children under-five were found stunted (16% severely stunted) and it also concluded that the prevalence of stunting increases with age. From the same survey, 17% children were considered wasted (3% severely wasted) and 41% of children were underweight (12% severely underweight). It was also reported that stunting, wasting and underweight were associated with place of residence (rural or urban), maternal education, age and nutritional status [2]. A framework developed by UNICEF recognizes the basic and underlying causes of under nutrition, including the environmental, economic, and sociopolitical contextual factors, with poverty having a central role. Previous studies have shown that multiple family and household characteristics were associated with malnutrition in under-five children [3-5]. Poor fetal growth and/or stunting in the first two years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income, and decreased off spring birth weight. On the other hand, children who are undernourished in the first two years of life and who put on weight rapidly later in childhood and in adolescence are at high risk of chronic diseases related to nutrition [6]. Before/within this period, nutrition interventions are most needed and have the greatest impact on child survival, health and development [7]. Investigators had identified several associated/risk factors for
under-five malnutrition in Bangladesh. But there is a paucity of literature reported the determinants of under nutrition in under-two year age group. METHODS This study used data of the National Nutrition Programme (NNP) baseline survey conducted in rural Bangladesh in 2004. The details of survey methodology, sample design and principle finding can be found elsewhere [8]. Z-scores of all anthropometric data were calculated in relation to the WHO growth standard by using WHO Anthro (version 2.0.2, 2007) software. Children are classified as moderately and severely stunted, wasted and underweight if the height for age z-score (HAZ), weight for height z-score (WHZ) and weight for age z-score (WAZ) are respectively below minus two and minus three z-score. Based on the available information, this study examined the influences of socioeconomic, demographic, health and community factors determining the nutritional status of less than two years old children. Bivariate analysis was performed to determine the differentials of under-two malnutrition by explanatory variables. Pearson s chi-square test was performed to test the existence of significant association between categories of malnutrition and selected factors. The significant variables observed in bivariate analysis were subsequently included in multivariate analysis. The multinomial logistic regression model was used to estimate regression parameters in multivariate analysis. Statistical analysis was done using the statistical software package SPSS 11.5 for windows and STATA 8. RESULTS Analysis of total 8,858 under-two children revealed that 40.5% of the children were stunted (15.6% severely stunted), 35.4% were underweight (11.5% severely underweight) and 17.8% were wasted (3% severely wasted). Bivariate analysis of demographic, health and nutrition care characteristics (the data are not shown) revealed that male children were significantly more underweight, stunted and wasted than the female children. Families of stunted, wasted and underweight children had less access to hygienic toilet facility. The long-term economic status of the households as indicated by asset index showed an inverse linear relationship with the occurrence of under nutrition. Too early or late initiation of complementary feeding practices was found negatively associated with under nutrition in bivariate analysis. Mothers of undernourished children had less exposure to mass media (television, radio and newspapers) and were less educated. Under nourished children suffered more often from diarrhea and other illness (including
fever, cough, common cold, pneumonia, ear infection, and/or skin diseases) in the previous two weeks of survey and similarly their families did not use iodized salt for cooking. The mothers who gave birth before 20 years and after 30 years of age had more chances to have stunted and wasted children. Stunted, wasted and underweighted children were more likely to have short statured ( 145 cm) and malnourished (BMI <18.5 kg/m 2 ), and non/less educated mothers (P<0.01). To identify the determinants of stunting, multivariate analysis (multinomial logistic regression) was performed. Table I shows that female children had 30% and 21% less odds to become moderately and severely stunted than the male counterparts, respectively. Multivariate analysis showed that female children had 20% to 21% less odds of being underweight (Web Table I). Moderately underweight children had greater number of aged, short stature and malnourished mother. On the other hand severely underweight children were associated with later two. Multivariate analysis revealed that severely wasted children were less likely to be female, vaccinated against measles, and consumed iodized salt for cooking. (Web Table II). DISCUSSION The present study reports on the level of under nutrition and the impact of some socioeconomic, demographical, health and nutrition care characteristics on the nutritional status of under two years old children of rural Bangladesh. As this survey included a large sample size and had a wide geographical coverage, it may reasonably be considered to reflect all under-two year rural children of Bangladesh. Mother s nutritional and educational statuses were found to be an important risk/associated factors for all three types of malnutrition. It was observed that highest rates of diarrhea occurred among malnourished children, likely due to the vicious cycle of the malnutrition infection interaction. Educational level of mother is important because educated mothers are more knowledgeable about their children s health and nutrition. They can make better use of health services, provide better care, have better hygienic practices and also have higher status in the family. It is also known that better economic conditions increase the living standard of the families, which allow them to take essential care of the children. That is why among most of the parameters of malnutrition, asset index was found to be a very important predictor. In agreement to our findings studies by Radhakrishna, et al. [9] and NFHS3, 2005-6 [10] maternal nutritional status, education and wealth index were found positively associated with all
types of childhood under nutrition. Similarly Rayhan, et al. [11] also found that mothers with secondary or higher level of education had likelihood of 37% and 30% less number of stunted and under weighted under-five children respectively than the illiterate mothers. In a cross country analysis from 63 countries, Smith and Haddad [12], found that women s education was strongly associated with child malnutrition in developing countries. Wamani, et al. [5] also reported maternal education was to be associated with stunting among under-two children in Uganda. The current study found that male sex, measles vaccination, diarrheal, illness in the last two weeks, and hygienic toilet availability were significant predictors of stunting among under-two population. Wamani, et al. [5] reported that male sex, maternal illiteracy, children without hygienic toilet facilities, and fever in last two weeks were significantly related with under-two stunting. Weaning, complementary feeding were found to be related with under-two under-weight status in that study [5]. We found these two variables to be significant only in bivariate analysis. No recent studies among Bangladeshi children found sex as predictor of malnutrition which was found to be significant for both chronic and acute forms of malnutrition in the current survey. In contrast to our finding Radhakrishna, et al. [9] reported that male children were more prone to become undernourished than the female children. Apart from wasting, measles vaccinated children had fewer chances to develop all other form of malnutrition. Measles vaccination may be considered as a proxy indicator as it was given at the age of nine months. So, those who were measles vaccinated are most likely to vaccinated against all other EPI diseases. Some important factors could not be considered in the current survey e.g. birth interval, birth order, size at birth, complementary feeding, father s education and occupation, those were found to be significant in the other studies [3, 6, 9, 11, 13], because these data were not captured in this survey. The causes of undernutrition in under-two children are complex and involve multiple factors. The current study specially suggests giving emphasis on maternal nutrition and education, measles vaccination of children, use of hygienic latrines and improvement of socio-economic status to reduce the burden of childhood under nutrition in this region. These above findings are expected to update knowledge of health scientists about possible determinants of under-two malnutrition. It may help the policy planners to develop strategies to combat different forms of malnutrition by targeting the high-risk groups.
What This Study Adds? Associated risk factors of undernutrition among under two year old children in Bangladesh included male sex, not receiving measles vaccine, diarrhea in previous two weeks, and older, shorter, undernourished, illiterate/less educated mother. Contributors credit: AMSA, TA and MIH: concept development, designed data collection and cleaning analyses and writing and revision of the draft; SKR and NA: concept development, designed analyses and revision of the draft. Funding: The study was funded by the Ministry of Health and Family Welfare, Government of Peoples Republic of Bangladesh, The World Bank, CIDA, and supported by ICDDR,B and its donors which provide unrestricted support to the Centre for its opens and research. Current donors providing unrestricted support include: Australian Agency for International Development (AusAID), Government of the People s Republic of Bangladesh, Canadian International Development Agency (CIDA), Embassy of the Kingdom of the Netherlands (EKN), Swedish International Development Coopen Agency (Sida), Swiss Agency for Development and Coopen (SDC), and Department for International Development (DFID), UK. Competing interests: None stated. REFERENCES 1. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, et al. Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet. 2008;371:243-60. 2. Bangladesh: Demographic and Health Survey 2007. Dhaka, Bangladesh and Calverton, Maryland [USA]: National Institute of Population Research and Training, Mitra and Associates, and ORC Marco. 3. Bairagi R, Chowdhury MK. Socioeconomic and anthropometric status and mortality of young children in rural Bangladesh. Int J Epidemiol. 1994;23:1197-281.
4. Rahman A, Chowdhury S. Determinants of chronic malnutrition among preschool children in Bangladesh. J Biosoc Sci. 2007;39:161-73. 5. Wamani H, Astrom AN, Peterson S, Tumwine JK, Tylleskär T. Predictors of poor anthropometric status among children under 2 years of age in rural Uganda. Public Health Nutrition. 2006;9: 320-6. 6. Victora CG, Adair L, Fall C, Hallal PC, Martorell R, Richter L, et al. Maternal and child undernutrition: consequences for adult health and human capital. Lancet. 2008;371:340-57. 7. Repositioning Nutrition as Central to Development. A Strategy for Large-Scale Action. The International Bank for Reconstruction and Development/The World Bank 2006. Washington, DC 20433 USA. 8. National Nutrition Programme: Baseline Survey 2004 Report. ICDDR,B, Dhaka. 9. Radhakrishna R, Ravi C. Malnutrition in India: Trends and determinants. Economic Political Weekly. 2004;39:671-6. 10. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-3), 2005-06: India Volume I. Mumbai: IIPL. 2007. 11. Rayhan MI, Khan SH. Factors causing malnutrition among under five children in Bangladesh. Pak J Nutr. 2006;5:558-62. 12. Smith Lisa C, Haddad L. Explaining child malnutrition in developing countries: a cross-country analysis. International Food Policy Research Institute. Washington, D.C. Research Report 111. [On line]. URL: http://www.ifpri.org/2020/briefs/brief64.pdf. Accessed on 31 December, 2011. 13. Nahar B, Ahmed T, Brown KH, Hossain MI. Risk factors associated with severe underweight among young children reporting to a diarrhoea treatment facility in Bangladesh. J Health Popul Nutr. 2010;28:476-83.
TABLE I FACTORS ASSOCIATED WITH MODERATE AND SEVERE STUNTING AMONG LESS THAN TWO YEARS OLD CHILDREN Characteristics Moderate Stunting (< 2 to 3 SD) Severe Stunting (<-3 SD) Total n % Odds 95% CI % Odds 95% CI Sex (female) 24.2 0.70** 0.59-0.82 13.7 0.79** 0.69-0.89 8,858 Measles vaccination 30.1 0.70** 0.58-0.85 21.1 0.80** 0.68-0.95 4,451 Diarrhea 29.1 1.26* 1.01-1.57 17.8 1.12 0.93-1.34 8,858 Suffering from any illness 24.5 1.24* 1.01-1.52 16.0 0.89 0.75-1.05 8.858 Maternal age <20 years 26.7 1.09 0.91-1.29 14.7 1.11 0.96-1.27 at child birth a 8046 >30 years 23.1 1.33** 1.08-1.64 20.9 1.02 0.85-1.22 Mother s height < 145 cm 31.3 3.47** 2.91 4.12 27.3 2.08** 1.78-2.43 8,851 Mother s BMI < 18.5 kg/m 2 28.2 1.47** 1.24-1.74 19.4 1.23** 1.09-1.39 8.837 Mother s Primary level 52.3 0.77** 0.64 0.93 30.9 0.89 0.76 1.04 education b Secondary 21.9 0.74* 0.59-0.93 10.9 0.79* 0.65-0.95 incomplete 8,667 Secondary 13 0.50** 0.31-0.79 7.4 0.47** 0.34-0.65 complete Hygienic toilet 18.5 0.74* 0.57 0.96 9.5 0.88 0.72 1.07 8.858 Asset Second 26.3 0.75** 0.60 0.92 18.4 0.77** 0.64-0.93 index c Middle 26.9 0.71** 0.56-0.89 16.1 0.79* 0.66-0.96 Fourth 24.1 0.54** 0.42-0.69 13.0 0.66** 0.54-0.81 8,858 Highest 16.6 0.35** 0.26-0.49 7.7 0.49** 0.38-0.63 According to WHO growth standards; Multivariate analysis done; Comparison group: a Maternal age at birth 20 to 30 years; b Illiterate mother; c Lowest quintile of asset index * P<0.05; ** P<0.01
WEB TABLE I FACTORS ASSOCIATED WITH MODERATE AND SEVERE UNDERWEIGHT AMONG LESS THAN TWO YEARS OLD CHILDREN Characteristics Moderate Under weight (WAZ < 2 to 3) Severe Under weight (WAZ <-3) Total n Odds 95% CI % Odds 95% CI % Sex (female) 22.2 0.79** 0.66 0.95 10.8 0.80** 0.70 0.91 8,858 Measles vaccination 29 0.65** 0.53-0.78 12.8 0.83* 0.70-0.99 4,451 Diarrhea 28.8 1.68** 1.31 2.15 16.1 1.44** 1.18-1.76 8,858 Asset index Suffering from any illness 24.3 1.17 0.92-1.49 12.0 1.19 0.99-1.42 8,858 Maternal age <20 years 24.7 1.04 0.86-1.26 10.3 1.11 0.95-1.29 at child birth a >30 years 25 1.31* 1.04-1.65 14.6 1.21 1.02-1.43 8046 Mother s height < 145 cm 30.2 2.78** 2.29 3.38 19.5 1.77** 1.53-2.05 8,851 Mother s BMI < 18.5 kg/m 2 28.8 1.92** 1.61 2.29 16.2 1.53** 1.35-1.73 8,837 Primary level 49.7 0.72** 0.59-0.88 22.6 0.87 0.74-1.01 Mother s Secondary 19.3 0.59** 0.46-0.78 7.0 0.78** 0.65-0.94 education b incomplete 8,667 Secondary 14.3 0.36** 0.22-0.59 1.9 0.49** 0.36-0.68 complete Hygienic toilet 17.7 0.71* 0.51-0.99 5.7 0.92 0.76-1.10 8,858 Middle 25.6 0.63** 0.51 0.79 11.1 0.75** 0.63-0.91 Fourth 20.7 0.52** 0.39-0.68 8.9 0.64** 0.52-0.80 8,858 c Second 28.4 0.79* 0.63-0.99 14.1 0.94 0.77-1.13 Highest 14.5 0.41** 0.28-0.61 4.4 0.49 0.37-0.63 According to WHO growth standards; Multivariate analysis done; Comparison group: a Maternal age at birth 20 to 30 years; b Illiterate mother; c Lowest quintile of asset index *P<0.05; ** P<0.01.
WEB TABLE II FACTORS ASSOCIATED WITH MODERATE AND SEVERE WASTING AMONG LESS THAN TWO YEARS OLD CHILDREN Moderate Wasting Severe Wasting Total (WHZ<-2 to -3) (WHZ <-3) n Characteristics Odds Odds % 95% CI % 95% CI Sex (female) 11.1 0.90 0.69 1.18 2.8 0.81** 0.69 0.95 8,858 Measles vaccination 13.6 0.74 0.52 1.07 3.0 0.64** 0.53 0.78 4,451 Diarrhea 15.1 1.86** 1.22 2.84 4.6 1.21 0.92 1.61 8,858 Suffering from any illness 12.2 1.03 0.68 1.57 3.1 1.09 0.86 1.39 8,858 Maternal age <20 years 11.3 1.12 0.81-1.57 2.7 0.96 0.80-1.15 at child birth a >30 years 13.1 1.38 0.96 1.99 4.0 0.96 0.77 1.19 8,046 Mother s height < 145 cm 13.7 1.13 0.79-1.62 3.6 1.26 1.04-1.53 8,851 Mother s BMI <18.5 kg/m 2 16.3 1.91** 1.45-2.52 4.5 1.79** 1.53-2.12 8,837 Mother s Primary level 12.5 0.71 0.49 1.02 5.8 0.79* 0.66 0.95 education b Secondary 9.5 0.55* 0.34-0.88 1.9 0.83 0.65-1.06 incomplete 8,667 Secondary 6.6 0.29* 0.11-0.75 1.1 0.67 0.43-1.05 complete Hygienic toilet 8.8 0.71 0.38-1.32 1.4 0.93 0.71-1.22 8,858 Asset index c Second 13.2 0.85 0.56-1.29 3.8 0.89 0.71-1.13 Middle 11.9 0.66 0.41-1.05 2.6 0.83 0.66-1.05 Fourth 10.1 0.74 0.44-1.23 2.4 0.73* 0.57-0.95 8,858 Highest 6.9 0.98 0.52 1.85 1.9 0.62** 0.44 0.88 According to WHO growth standards; Multivariate analysis done; Comparison group: a Maternal age at birth 20 to 30 years; b Illiterate mother; c Lowest quintile of asset index * P<0.05; ** P<0.01.