A systematic review of the prevalence and predictors of the double burden of malnutrition within households

Influence of Maternal Education and Household Wealth on Double Burden of Malnutrition in South and Southeast Asia

The double burden of malnutrition (DBM), defined by the coexistence of undernutrition and overnutrition within households, poses significant public health challenges in South and Southeast Asia. While previous studies have examined the individual effects of maternal education and household wealth on DBM, findings remain inconsistent, and little is known about how these factors interact across different contexts. To address this gap, we used nationally representative Demographic and Health Survey (DHS) data from Bangladesh (2017-2018), Cambodia (2022), Nepal (2022) and Timor-Leste (2016) to analyse the interaction between maternal education and household wealth in shaping DBM risk. These countries were selected due to their ongoing nutritional transition, which has contributed to the increasing prevalence of DBM. For the analysis, we used DHS data, which employs a standardised multistage cluster sampling method and probabilistic methods to ensure representativeness. In this study, we selected mother-child pairs from the DHS survey, focusing on children aged 0-59 months and nonpregnant mothers at the time of the survey. We included those pairs for which both the mother and child had valid weight and height measurements. Maternal education and household wealth were identified as the primary exposures. To examine their interaction and the impact of other covariates on DBM, we employed multivariable logistic regression models. Our study found that DBM prevalence was higher in urban and wealthier households, with the highest rates observed in Timor-Leste and Cambodia. Multivariable logistic regression indicated that lower maternal education increased DBM risk, especially in affluent households (OR 2.07-3.29). Conversely, higher maternal education was associated with lower DBM prevalence. Additionally, breastfeeding and antenatal care visits emerged as protective factors. These findings indicate the necessity for specific interventions aimed at enhancing maternal education and promoting healthy dietary practices, particularly in rich households. Additionally, reinforcing breastfeeding practices and increasing antenatal care visits are essential strategies to mitigate the risks associated with DBM.

A Nutritional and Anthropometric Analysis of the Double Burden of Malnutrition in Children Under Two in Madagascar

Background: Almost half of all deaths worldwide in children under five are related to malnutrition. Malnutrition encompasses a wide array of nutritional conditions and emerging evidence indicates a growing overlap of these different forms of malnutrition. Nutrimetry, which combines assessments of height-for-age (HAZ) with BMI-for-age (BMIZ) to offer a more integrated assessment of nutritional status, can be particularly useful in low-resource settings to correctly reflect the complex interplay of stunting and overweight. Objective: The objective of this study is to explore the impact of malnutrition on children in Madagascar and demonstrate how integrating HAZ assessments with BMIZ can reveal the double burden of malnutrition-encompassing both undernutrition and overnutrition-within the same population. Methods: This cross-sectional observational study employing Nutrimetry was carried out in rural communities in the Itasy region of Madagascar. A systematic random sampling method was used to choose the 500 women to invite to participate from the approximately 5000 who formed the pool of potential participants. A total of 437 were able to be invited and all invited women agreed to participate, resulting in 437 mother-child (0-24 months) pairs being included in the study. Results: Chronic undernutrition or thinness (31.6%), overweight and obesity (21.3%), and stunting (57.6%) were prevalent among the children included in the study. Among children with chronic undernutrition, 55.06% were identified as stunted. Among children with overweight or obese, 61.03% were identified as stunted. This highlights a significant overlap between inadequate weight and stunting. A socioeconomic analysis revealed significant barriers, including limited financial resources and poor dietary diversity, exacerbating malnutrition. Maternal nutritional status and breastfeeding practices also emerged as critical determinants of child nutritional outcomes. Conclusions: The study underscores the importance of prioritizing height assessments as a preliminary step in nutritional evaluations to prevent undetected acute malnutrition.

Concordance of weight status between mothers and children: a secondary analysis of the Pakistan Demographic and health survey VII

BACKGROUND

Familial concordance of weight status is an emerging field of study that may guide the development of interventions that operate beyond the individual and within the family context. There is a dearth of published data for concordance of weight status within Pakistani households.

METHODS

We assessed the associations between weight status of mothers and their children in a nationally representative sample of households in Pakistan using Demographic and Health Survey data from 2017-18. Our analysis included 3465 mother-child dyads, restricting to children under-five years of age with body mass index (BMI) information on their mothers. We used linear regression models to assess the associations between maternal BMI category (underweight, normal weight, overweight, obese) and child's weight-for-height z-score (WHZ), accounting for socio-demographic characteristics of mothers and children. We assessed these relationships in all children under-five and also stratified by age of children (younger than 2 years and 2 to 5 years).

RESULTS

In all children under-five and in children 2 to 5 years, maternal BMI was positively associated with child's WHZ. For all children under-five, children of normal weight, overweight, and obese women had WHZ scores that were 0.21 [95% CI (confidence interval): 0.04, 0.37], 0.43 [95% CI: 0.25, 0.62], and 0.51 [95% CI: 0.30, 0.71] units higher than children of underweight women, respectively. For children ages 2 to 5, children of normal weight, overweight, and obese women had WHZ scores that were 0.26 [95% CI: 0.08, 0.44), 0.50 [95% CI: 0.30, 0.71), and 0.61 [95% CI: 0.37, 0.84] units higher than children of underweight women, respectively. There was no association between maternal BMI and child WHZ for children under-two.

CONCLUSIONS

The findings indicate that the weight status of mother's is positively associated with that of their children, particularly after age 2. These associations further strengthen the call for research regarding interventions and policies aimed at healthy weight promotion among mothers and their children collectively, rather than focusing on individuals in isolation.

Co-existence of maternal overweight/obesity, child undernutrition, and anaemia among mother-child pairs in Ethiopia

Ethiopia is currently known to be the most food-insecure country in sub-Saharan Africa, where childhood undernutrition remains endemic. While attention is increasingly being paid to childhood undernutrition in Ethiopia, a current surge of "triple burden of malnutrition" (TBM) has received less attention. The purpose of this study was to determine the prevalence of TBM and identify the associated factors in Ethiopia. Data were from the Ethiopian Demographic and Health Surveys (2005-2016) and a total of 20,994 mother-child pairs were examined in this study. The TBM was our primary outcome variable, which encompasses three types of nutritional problems-when a mother may be overweight/obese, while her child is stunted, wasted, or underweight plus has anaemia under the same roof. A multilevel logistic regression explored the individual- and community-level factors associated with TBM. Our study indicated that children under-five years of age were anaemic, stunted, wasted, and underweight [49.3% (95% CI: 48.7-49.9), 43.1% (95% CI: 42.4-43.7), 10.3% (95% CI: 9.9-10.7), and 27.6% (95% CI: 27.0-28.1)] respectively. The overall prevalence of TBM was 2.6% (95% CI: 2.39-2.83). Multilevel analyses revealed that TBM was more likely to occur among children aged 12-23 months (AOR: 2.54, 95% CI: 1.68-3.83), 24-35 months (AOR: 1.54, 95% CI: 1.03-2.29), children perceived by their mothers to be smaller than normal at birth (AOR: 1.94, 95% CI: 1.48-2.56), who experienced fever in the past 2 weeks (AOR: 1.58, 95% CI: 1.24-2.01), and lived in urban settings (AOR: 1.79, 95% CI: 1.13-2.86). Lower odds of TBM were reported among female children (AOR: 0.59, 95% CI: 0.47-0.72), and those who lived in rich households (AOR: 0.69: 95% CI: 0.49-0.98). TBM was found to be present in almost three percent of households in Ethiopia. Addressing the TBM through double-duty actions will be of critical importance in achieving malnutrition in all its forms in Ethiopia.

Understanding the national evidence on the double burden of malnutrition in Ethiopia for the implications of research gap identifications: a scoping review

BACKGROUND

Owing to the unavoidable consequences of nutritional transition, the double burden of malnutrition (DBM) is an emerging public health problem. An increasing number of studies have found that Ethiopians face a DBM. However, country-level evidence has not yet been summarised using a scoping review study design.

OBJECTIVE

The main objective of this review was to map the national evidence on DBM in Ethiopia for the implications of research gap identifications.

ELIGIBILITY CRITERIA

The population, concept and context approach was used. All age groups, box sexes, all dates of publication and articles in English language focused on DBM conducted in Ethiopia were included.

SOURCES OF EVIDENCE

Primary research articles, systematic reviews, meta-analyses and scoping reviews searched from electronic databases such as PubMed, ScienceDirect, Cochrane Library, Wiley Online Library, Google Scholar and Google were the sources of evidence.

CHARTING METHODS

The Joanna Briggs Institute Reviewer's manual was used as a review methodology. The authors, publication year, region, study design, sample size, population group, measured outcomes and main findings were charted in a table.

RESULTS

A total of 35 articles met the inclusion criteria among 124 426 participants. The average summarised prevalence of DBM was 33.6%, with the average proportions of undernutrition and overnutrition at 21.5% and 12.1%, respectively. The major factors that influenced the DBM were categorised as child, maternal, adolescent, household and adult-related factors.

CONCLUSION

In Ethiopia, the overall prevalence of DBM is high, which makes one-third of the population affected by DBM. The foremost determinant factors that influenced the DBM were characterised as child, maternal, adolescent, household and adult-related factors. Therefore, a double-duty interventions should be used to address DBM, considering multilevel factors at the individual, community and societal levels.

PROTOCOL REGISTRATION

This review was registered on the figshare website on 28 February 2021, with DOI number https://doi.org/10.6084/m9.figshare.14131874. The review protocol was published with a DOI number http://dx.doi.org/10.1136/bmjopen-2021-050805.

A multilevel analysis of the triple burden of malnutrition in Indonesia: trends and determinants from repeated cross-sectional surveys

BACKGROUND

Although child malnutrition has been reducing, the coexistence in mothers and children of various forms of malnutrition has continued to rise around the world. In the Indonesian context, a knowledge gap exists on the coexistence of multiple malnutrition burdens. This study examines trends in the coexistence of the triple burden of malnutrition (TBM) among mother-child pairs living in the same house and explores multilevel (individual, household, and community) factors associated with TBM in Indonesia.

METHODS

We used data from the 2013 and 2018 Indonesia Basic Health Research, the nationally representative survey of the Indonesian population, as repeated cross-sectional surveys. Study samples were mothers and children (0-59 months old), who resided in the same household and indicated by the same identifier number. The anthropometric measurements of the mothers and children, and the hemoglobin levels of the children were collected. We employed a multilevel mixed-effects model to consider the hierarchical data structure. The model captured the role of cluster, district, provincial differences, and the individual, household, community-level, and TBM status characteristics.

RESULTS

Of 3,891 mother-child pairs analyzed, 24.9% experienced TBM. Girls had 63% higher odds than boys of TBM (aOR: 1.63; 95% CI: 1.30 to 2.03). Significantly lower odds were found in children of mothers who had a gestational age lower than 37 weeks (aOR: 0.72; 95% CI: 0.55 to 0.94). At the household level, children with a father who had a high-school, primary-school, or no school education had significantly higher odds of TBM than children of fathers who had graduated from academy. Children of mothers who visited Antenatal Care (ANC) no more than 6 times had significantly lower odds (aOR: 0.65; 95% CI: 0.47 to 0.88). Children of mothers who consumed Iron and Folic Acid (IFA) supplements had significantly lower odds.

CONCLUSION

TBM is related to characteristics at not just the individual level but also the family and community levels. To achieve significant outcomes, integrated nutrition interventions in Indonesia should also consider family and community factors.

Exploring the double burden of malnutrition at the household level in the Philippines: Analysis of National Nutrition Survey data

BACKGROUND

In the Philippines, the rising prevalence of obesity and related chronic diseases alongside persistent undernutrition presents a complex public health challenge. Understanding the patterns and dynamics of this 'double burden of malnutrition' (DBM) is crucial for developing effective intervention strategies. However, evidence of the occurrence of undernutrition and overnutrition within the same household is currently lacking.

METHODS

Using cross-sectional data from the 2013 Philippines National Nutrition Survey this study examined the prevalence of different typologies of household-level DBM from an analytical sample of 5,837 households and 25,417 individuals. Multivariable logistic regression was performed to identify factors associated with overall occurrence of intrahousehold DBM.

RESULTS

The overall prevalence of double burden households was 56% based on a comprehensive definition. The most common typology of intrahousehold DBM characterized in this study (% of all households) comprised households with at least one adult with overnutrition and at least one separate adult with undernutrition. Household size, wealth quintile, food insecurity, and household dietary diversity were all associated with household-level DBM. Double burden households were also influenced by head of household characteristics, including sex, level of education, employment status, and age.

CONCLUSIONS

The findings from this study reveal that the coexistence of overnutrition and undernutrition at the household level is a major public health concern in the Philippines. Further comprehensive assessments of household-level manifestations of the DBM are needed to improve our understanding of the trends and drivers of this phenomenon in order to develop better targeted interventions.

The double burden of malnutrition among women of reproductive age and preschool children in low- and middle-income countries: A scoping review and thematic analysis of literature

The aim of this review was to map the literature on the double burden of malnutrition (DBM) among women of reproductive age (WRA) and preschool children in low- and middle-income countries (LMICs). The study aimed to provide an understanding of how DBM construct has been defined in the current literature and to elucidate plausible mechanisms underlying DBM development and its common risk factor among the two subgroups. We systematically searched for literature from the following databases: EMBASE, CINAHL, MEDLINE, LILACS, Scopus and ProQuest Dissertations & Thesis Global and identified articles that specifically reported on the coexistence of undernutrition and overnutrition sequalae at the population, household, or individual levels among WRA and preschool children in LMICs. A thematic analysis using the Braun and Clarke approach was conducted on excerpts from the articles to reveal emerging themes underlying the occurrence of DBM from the included studies. Of the initial 15 112 articles found, 720 met the inclusion criteria. Anthropometric measures for overnutrition and undernutrition including body mass index for WRA and height-for-age, weight-for-age, and weight-for-height Z-scores for preschool children were frequently used indicators for defining DBM across all levels of assessment. In fewer cases, DBM was defined by the pairing of cardiometabolic risk factors (e.g., hypertension) as measures for overnutrition and micronutrient deficiency (e.g., iron deficiency) as measures for undernutrition. The following themes emerged as plausible mechanisms for DBM development: nutrition transition, breastfeeding, diet behavior, biological mechanism, and statistical artifact. Factors such as child age, child sex, maternal age, maternal education, maternal occupation, household food security, household wealth, urbanicity, and economic development were commonly associated with most of the DBM phenotypes. Our review findings showed that the understanding of the DBM in current literature is very ambiguous. There is need for future research to better understand the DBM construct and its etiology.

National income and macro-economic correlates of the double burden of malnutrition: an ecological study of adult populations in 188 countries over 42 years

BACKGROUND

The double burden of malnutrition (DBM) represents a growing global challenge with adverse health and economic consequences. We aimed to investigate the associative roles of national income (gross domestic product per capita [GDPPC]) and macro-environmental factors on the DBM trends among national adult populations.

METHODS

In this ecological study we assembled extensive historical data on GDPPC from the World Bank World Development Indicators database and population-level DBM data of adults (aged ≥18 years) from the WHO Global Health Observatory database in 188 countries over 42 years (1975-2016). In our analysis, a country was considered to have the DBM in a year when adult overweight (BMI ≥25·0 kg/m²) and underweight (BMI <18·5 kg/m²) prevalence was each 10% or more in that year. We used a Type 2 Tobit model to estimate the association of GDPPC and selected macro-environmental factors (globalisation index, adult literacy rate, female share in the labour force, share of agriculture in the national gross domestic product [GDP], prevalence of undernourishment, and percentage of principal display area mandated to be covered by health warnings on cigarette packaging) with DBM in 122 countries.

FINDINGS

We find a negative association between GDPPC and the likelihood of a country having the DBM. However, conditional on its presence, DBM level exhibits an inverted-U shaped association with GDPPC. We found an upward shift in DBM levels from 1975 to 2016 across countries at the same level of GDPPC. Among the macro-environmental variables, share of females in the labour force and share of agriculture in the national GDP are negatively associated with DBM presence in a country, whereas the prevalence of undernourishment in the population is positively associated. Further, globalisation index, adult literacy rate, share of females in the labour force, and health warnings on cigarette packaging are negatively associated with DBM levels in countries.

INTERPRETATION

DBM level in national adult populations rises with GDPPC until US$11 113 (in 2021 constant dollar terms) and then starts declining. Given their current GDPPC levels, most low-income and middle-income countries are thus unlikely to have a decline in the DBM levels in the near future, ceteris paribus. Those countries will also be expected to experience a higher DBM level at similar levels of national income than were historically experienced by the current high-income countries. Our findings point to a further intensification of the DBM challenge in the near future for the low-income and middle-income countries as they continue to have income growth.

FUNDING

None.

Analysis of predictors of malnutrition in adult hospitalized patients: social determinants and food security

Background

Malnutrition in hospitalized patients is becoming a priority during the patient care process due to its implications for worsening health outcomes. It can be the result of numerous social factors beyond clinical ones. This study aimed to evaluate the link between these various risk factors considered social determinants of health, food security levels, and malnutrition and to identify potential predictors.

Methods

A cross-sectional observational study was conducted on a random sample of adult patients in five different hospitals in Lebanon. Malnutrition was assessed using the Global Leadership Initiative on Malnutrition (GLIM) criteria. Patients were interviewed to collect social and economic characteristics and were categorized into four criteria: (1) area of residence (urbanization level), (2) level of education, (3) employment status, and (4) source of health coverage. The food security level was screened by a validated two-question tool, adapted from the US Department of Agriculture Household Food Security Survey, targeting both quantity and quality.

Results

In a random sample of 343 patients, the prevalence of malnutrition according to the GLIM criteria was 35.6%. Patients with low levels of food security, mainly low quality of food, had higher odds of being malnourished (OR = 2.93). Unemployed or retired patients and those who have only completed only elementary school had higher odds of being diagnosed with malnutrition as compared to those who were employed or had university degrees, respectively (OR = 4.11 and OR = 2.33, respectively). Employment status, education level, and type of health coverage were identified as predictors of malnutrition in the multiple regression model. Household location (urban vs. rural) was not associated with malnutrition.

Conclusion

The social determinants of health identified in our study, mainly the level of education and income level, in addition to food security, were identified as predictors of malnutrition in hospitalized patients. These findings should guide healthcare professionals and national policies to adopt a broader perspective in targeting malnutrition by including social determinants in their nutrition care.

Concordance of weight status between mothers and children: A secondary analysis of the Pakistan Demographic and Health Survey VII

Familial concordance of nutritional status is an emerging field of study that may guide the development of interventions that operate beyond the individual and within the family context. Little published data exist for concordance of nutritional status within Pakistani households. We assessed the associations between weight status of mothers and their children in a nationally representative sample of households in Pakistan using Demographic and Health Survey data. Our analysis included 3465 mother-child dyads, restricting to children under-five years of age with body mass index (BMI) information on their mothers. We used linear regression models to assess the associations between maternal BMI category (underweight, normal weight, overweight, obese) and child's weight-for-height z-score (WHZ), accounting for socio-demographic characteristics of mothers and children. We assessed these relationships in all children under-five and also stratified by age of children (younger than 2 years and 2 to 5 years). In all children under-five and in children 2 to 5 years, maternal BMI was positively associated with child's WHZ, while there was no association between maternal BMI and child WHZ for children under-two. The findings indicate that the weight status of mother's is positively associated with that of their children. These associations have implications for interventions aimed at healthy weights of families.

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.

Association Between Parental Education and Simultaneous Malnutrition Among Parents and Children in 45 Low- and Middle-Income Countries

IMPORTANCE

Parental education is known to be associated with the health status of parents and their offspring. However, the association between parental education and the simultaneous manifestation of multiple forms of malnutrition within households remains underinvestigated globally.

OBJECTIVE

To assess the association between parental education and the simultaneous manifestation of malnutrition of both parent and child (either overnutrition or undernutrition)-referred to as the double burden of malnutrition (DBM)-at the household level in mother-child and father-child pairs in low- and middle-income countries (LMICs).

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the US Agency for International Development Demographic and Health Surveys (January 1, 2010, to December 31, 2021) to identify mother-child pairs and father-child pairs from LMICs. The eligibility criteria were as follows: (1) children aged 0 to 59 months; (2) nonpregnant mothers at the time of the survey in the sample of mother-child pairs; and (3) valid measures of the weight, height, and hemoglobin level for the child and at least 1 of their parents.

EXPOSURES

Highest level of parental education obtained and number of years of education completed.

MAIN OUTCOMES AND MEASURES

Four sets of multivariable logistic regression models were constructed to assess the association between parental education and DBM, and analysis was performed between March 10 and May 15, 2022.

RESULTS

This study included 423 340 mother-child pairs from 45 LMICs and 56 720 father-child pairs from 16 LMICs. The mean (SD) age of the mother-child pairs was 28.2 (6.1) and 1.9 (1.4) years, respectively; 48.8% of the children were female. We observed that 49.0% of mother-child pairs experienced DBM. Compared with mother-child pairs with no maternal education, higher maternal education was associated with a lower risk of DBM. For example, the odds ratio (OR) for tertiary maternal education was 0.71 (95% CI, 0.67-0.74). However, the association differed by DBM subtypes: higher maternal education was associated with a lower risk of both mothers and children being undernourished but with a higher risk of almost all DBM subtypes involving overnutrition. For example, compared with mother-child pairs with no maternal education, those with secondary education were less likely to develop simultaneous maternal and child undernutrition (OR, 0.83 [95% CI, 0.80-0.86]) but were more likely to experience simultaneous maternal and child overnutrition (OR, 2.20 [95% CI, 1.61-3.00]); similar results were observed for pairs with primary and tertiary education. The results in mother-child pairs remained consistent after controlling for paternal education. Among the father-child pairs, 26.5% had DBM, with fathers with tertiary education significantly more likely to experience simultaneous paternal overnutrition and child undernutrition (OR, 1.55 [95% CI, 1.23-1.95]) compared with pairs with no paternal education; they were also less likely to have both paternal and child undernutrition (OR, 0.70 [95% CI, 0.59-0.84]).

CONCLUSIONS AND RELEVANCE

In this study, maternal education and paternal education were independently associated with DBM, and the associations differed by DBM subtypes. These findings suggest that the different risks of malnutrition faced by households with various levels of education should thus be considered in policy evaluation.

Are stunted child - overweight mother pairs a real defined entity or a statistical artifact?

In a methodological contribution, Dieffenbach & Stein (DS) (The Journal of Nutrition, 142(4), 771-773.) concluded that the double burden of malnutrition (DBM), represented by stunted child - overweight mother pairs (SCOM), is a statistical artifact, meaning that SCOM does not describe a unique phenomenon because the observed rates of SCOM across a number of countries were not strongly different from the product of observed rates of maternal overweight (OM) and child stunting (SC), which DS referred to as the expected rate of SCOM. However, a growing literature continues to use SCOM as an indicator of the DBM. This study shows that the analysis by DS is not sufficient to conclude that SCOM can be explained by the co-occurrence of OM and SC due to chance alone because the analysis by DS was conducted at the country level, but applied to SCOM, which is a household-level variable. Using Demographic and Health Surveys data from 202 country-year data sets, we do not confirm important implicit assumptions that are required for the claim by DS to be supported. We also outline that comparing the expected to the observed rate of SCOM is primarily informative when putting it in relation to factors that influence the supply and demand of food consumed by households. When considering these factors, we find further evidence that it is misleading to consider SCOM as a statistical artifact, as the difference between the observed and the expected rate of SCOM significantly differs by household wealth. Recognizing that SCOM is a distinct phenomenon is important for policymakers who develop double-duty strategies that address malnutrition, and for researchers who need useful indicators to study the determinants of malnutrition at the household level.

Individual and contextual factors associated with childhood malnutrition: a multilevel analysis of the double burden of childhood malnutrition in 27 countries

BACKGROUND

Malnutrition is a key global health challenge and a major contributor to childhood morbidity and mortality. In recent times, the contrasting coexistence of undernutrition including micronutrient deficiencies and overweight/obesity called double burden of malnutrition has been noted at individual, household or population level and/or at different times in life. The objective of this study was to examine individual, neighborhood and country level factors that are associated with the double burden of childhood malnutrition.

METHODS

We conducted multivariable multilevel logistic regression analyses on the most recent demographic and health datasets from surveys conducted between 2015 and 2020 in low- and middle-income countries. We analyzed data of 138,782 children (level 1) living in 13,788 communities (level 2) from 27 countries (level 3).

RESULTS

The results of our analysis show variation in childhood malnutrition across the 27 countries from as low as 6.5% in Burundi to as high as 29.5% in Timor Leste. After adjusting for all level factors, we found that those who were wasted/overweight tended to have had an episode of diarrhea or fever in the last two weeks preceding the survey, were part of a multiple birth, were being breastfed at the time of the survey and born to mothers with more than one under 5-child resident in neighborhoods with high illiteracy and unemployment rates. The intra-neighbourhood and intra-country correlation coefficients were estimated using the intercept component variance; 44.3% and 21.0% of variance in odds of double burden of childhood malnutrition are consequent upon neighborhood and country level factors respectively.

CONCLUSIONS

Evidence of geographical clustering in childhood malnutrition at community and country levels was found in our study with variability due to neighborhood level factors twice that of country level factors. Therefore, strategies in tackling the double burden of malnutrition must consider these shared drivers, contextual barriers and geographical clustering effects.

Double burden of malnutrition as a risk factor for overweight and obesity

OBJECTIVE

To assess the longitudinal effect of double burden of malnutrition (DBM) on the risk of developing child and adolescent overweight or obesity.

METHODS

Analysis of the Peruvian Young Lives Study, younger cohort: baseline (2002) and 4 follow-ups (2006-2007, 2009-2010, 2013-2014, and 2016-2017). Outcomes were the incidence of overweight and obesity as defined by the World Health Organization standards. The exposure comprised a variable with 4 categories: non-stunted child with a non-overweight mother (reference group), non-stunted child with an overweight mother, stunted child with a non-overweight mother, and stunted child with an overweight mother (i.e., DBM). Poisson regression models were built to assess the association of interest, and relative risks (RR) and 95%CI were reported.

RESULTS

Data from 2,034 children; 50.0% were girls and the mean age was 12.0 (3.6) months at baseline. Non-stunted children with an overweight mother had greater risk (RR = 1.64; 95%CI: 1.35-1.99) of developing overweight, compared with the risk for stunted children with a non-overweight mother (RR = 1.38; 95%CI: 1.10-1.72), and for those with DBM (RR = 1.28; 95%CI: 1.02-1.61). When compared with the reference group, obesity risk was greater among non-stunted children with an overweight mother (RR = 2.33; 95%CI: 1.68-3.22), greater among stunted children with a non-overweight mother (RR = 2.59; 95%CI: 1.75-3.84), and greater among those with DBM (RR = 2.14; 95%CI: 1.39-3.28).

CONCLUSIONS

DBM is a risk factor for childhood overweight and obesity in Peru. Dual-duty policies tackling both undernutrition in children and overweight in mothers are needed to reduce DBM and its future effects in Peru.

Evidence of Concurrent Stunting and Obesity among Children under 2 Years from Socio-Economically Disadvantaged Backgrounds in the Era of the Integrated Nutrition Programme in South Africa

In view of persistent stunting and increasing rates of obesity coexisting among children in the era of the Integrated Nutrition Programme, a cross-sectional study was conducted to determined concurrent stunting and obesity (CSO) and related factors using a random sample of child-mother pairs (n = 400) in Mbombela, South Africa. Sociodemographic data was collected using a validated questionnaire, and stunting (≥2SD) and obesity (>3SD) were assessed through respective length-for-age (LAZ) and body mass index (BAZ) z-scores. Using SPSS 26.0, the mean age of children was 8 (4; 11) months, and poor sociodemographic status was observed, in terms of maternal singlehood (73%), no education or attaining primary education only (21%), being unemployed (79%), living in households with a monthly income below R10,000 (≈$617), and poor sanitation (84%). The z-test for a single proportion showed a significant difference between the prevalence of CSO (41%) and non-CSO (69%). Testing for the two hypotheses using the Chi-square test showed no significant difference of CSO between boys (40%) and girls (41%), while CSO was significantly different and high among children aged 6-11 months (55%), compared to those aged 0-5 months (35%) and ≥12 months (30%). Further analysis using hierarchical logistic regression showed significant associations of CSO with employment (AOR = 0.34; 95%CI: 0.14-0.78), maternal education status (AOR = 0.39; 95%CI: 0.14-1.09) and water access (AOR = 2.47; 95%CI: 1.32; 4.63). Evidence-based and multilevel intervention programs aiming to prevent CSO and addressing stunting, while improving weight status in children with social disadvantages, are necessary.

Double burden of malnutrition among migrants and refugees in developed countries: A mixed-methods systematic review

Migrants and refugees living in high income countries (HICs) have an increased risk of developing non-communicable diseases (NCDs) due to malnutrition at different stages over their life course. This systematic review aims to examine the double burden of malnutrition (DBM) among migrants and refugees in developed countries. This review was informed by the standard Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines. Eligible studies were peer-reviewed observational studies that focused on the DBM in refugee or migrant populations; and were written in English with full texts available and accessible. A combination of keywords was used to search 8 electronic bibliographic databases including Ovid MEDLINE, EMBASE, PsycINFO, CINAHL, ProQuest, Scopus, PubMed, and web of science. There is a paucity of research into the DBM among migrants and refugees residing in HICs. Of a total of 2344 articles retrieved from eight databases, 5 studies met the inclusion criteria. All included studies showed the co-existence of some form of undernutrition and overnutrition within the same population. Overnutrition (overweight and obesity) in the studied populations ranged from 11.1% to 42% while undernutrition (stunting, wasting and underweight) ranged from 0.3% to 17%. Standard measures for anthropometry as determined by World Health Organization (WHO) were used for data collection in all included studies. A piloted form informed by the Cochrane Public Health Group Data Extraction and Assessment Template was used in the extraction of data from retrieved studies. Quality assessment of included studies was performed using the study assessment tools of the National Heart, Lung, and Blood Institute of the National Institutes of Health (NIH) and showed that all studies were of fair quality. Interventions that simultaneously target more than one form of malnutrition especially amongst migrant and refugee populations must be implemented for policy solutions to be effective. This review has been registered by the PROSPERO international prospective registry for systematic reviews, reference CRD42020192416.

Co-existence of overweight/obesity and stunting: it's prevalence and associated factors among under - five children in Addis Ababa, Ethiopia

Background

Double burden of malnutrition is a global problem posing a serious public health challenge especially in low- and middle-income countries including Ethiopia, where a high prevalence of under-nutrition continues to exist and overweight is increasing at an alarming rate. Although both under-nutrition and over-nutrition are investigated extensively in Ethiopia, evidence about the double burden of malnutrition especially at the individual level is very limited.

Objective

To assess the prevalence of the co-existence of overweight/obesity and stunting and associated factors among under-five children in Addis Ababa, Ethiopia at an individual level.

Methods

Institution-based cross-sectional study was conducted from May to June 2021 among 422 mothers to child pairs in Addis Ababa. Twenty-nine (30%) of the health centers in Addis Ababa were selected to take part in the study using a simple random sampling technique. The total sample size was allocated proportionally to each of the selected health centers based on their performances within 6 months prior to the study. A systematic random sampling method was used to select the study participants. An interviewer-administered structured questionnaire was used to collect data. Descriptive statistics and a hierarchical logistic regression model were used to characterize the study population and to identify factors that are associated with the outcome variable respectively. Odds ratio along with 95% CI were estimated to measure the strength of the association. The level of statistical significance was declared at a p-value less than 0.05.

Results

The prevalence of the co-existence of overweight/obesity and stunting was 5.1% with 95% CI (2.9–7.1%). The hierarchical logistic regression analysis revealed that child age (6–23 months) [(AOR = 2.86, 95% CI: (1.02–8.04)], maternal education status (non-educated) [(AOR = 4.98, 95% CI: (1.33–18.66)], maternal age during birth (≥ 28 years) [(AOR = 0.22, 95% CI: (0.06–0.79)] and childbirth order (3+) [(AOR = 6.38, 95% CI: (1.03–39.7)] were significantly associated with the co-existence of overweight /obesity and stunting. Conclusion and recommendations: The study revealed that the prevalence of the co-existence of overweight/obesity and stunting is low in Ethiopia. However, local and national nutrition policies and programs should be tailored and implemented to simultaneously address both under-nutrition and over-nutrition.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12887-022-03445-5.

Examining the double burden of malnutrition for preschool children and women of reproductive age in low-income and middle-income countries: a scoping review protocol

INTRODUCTION

The majority of the populations in low-income and middle-income countries (LMICs) are encountering the double burden of malnutrition (DBM): the coexistence of both undernutrition and overnutrition sequalae. With DBM being a new phenomenon in research, little is known about its aetiology, operational definitions and risk factors influencing its manifestation. The proposed scoping review is aimed at mapping literature with regard to the DBM phenomenon among preschool children and women of reproductive age in LMICs who are among the most high-risk groups to encounter DBM.

METHODS

A comprehensive literature search will be conducted in the following electronic databases: MEDLINE, EMBASE, Scopus, CINAHL, LILACS and ProQuest Dissertations and Thesis Global. Additionally, searches in other government and institutional sources (WHO website and university repositories) and forward and backward citation tracking of seminal articles will also be done. Two reviewers will independently conduct title and abstract screening and full-text screening. Similarly, data extraction and coding will independently be done by two reviewers. Information extracted from included literature will be analysed qualitatively using thematic analysis approach and reported as per the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews guidelines.

ETHICS AND DISSEMINATION

Ethical approval is not required for this study because the review is based on literature from publicly available sources. The dissemination of our findings will be done through presentations in relevant conferences and publication in a peer-reviewed journal.

Predictor of Obese Mothers and Stunted Children in the Same Roof: A Population-Based Study in the Urban Poor Setting Indonesia

Stunting leads to the poor cognitive development, increases the risk of child mortality, and elevates the risk of non-communicable diseases. This study aimed to determine the magnitude of double burden of malnutrition (DBM) in the urban poor setting in Indonesia and investigate its predictors. This was a cross-sectional study involving 436 mothers proportionally chosen from 16 integrated health posts in Surabaya, Indonesia. The households were categorized into the two groups based on the body mass index (BMI) of mother and the height-for-age z-score (HAZ) of child; households without DBM and household with DBM. Energy, carbohydrate, protein, and fat intake were obtained using 24-h food recall and socioeconomic status was measured using a structured questionnaire. Data on socioeconomic status were educational level of mother and occupation, household income, and food expenditure. The prevalence of household with DBM was 27.5%; 12.4% pair stunted children and normal weight mother; 45.6% pair of overweight/obese mother and normal height children. The logistic regression analysis showed significant differences in the education level and occupation of mother, protein intake of the children, and fat intake of the mother between households with and without DBM. This study offers an important insight to improve the knowledge of mother related to the protein intake of children to reduce stunting risk and fat intake of mother to prevent over-nutrition.

Malnutrition in children under the age of 5 years in a primary health care setting

In this study, we outlined the types of malnutrition amongst children, the causes of malnutrition intervention at the primary health care level and some recommendations to alleviate childhood malnutrition in South Africa.

Urbanization in Peru is inversely associated with double burden of malnutrition: Pooled analysis of 92,841 mother-child pairs

OBJECTIVE

This study assessed the relationship between urbanization and the double burden of malnutrition (DBM) in Peru.

METHODS

A cross-sectional analysis of the Demographic and Health Survey (2009 to 2016) was conducted. A DBM "case" comprised a child with undernutrition and a mother with overweight/obesity. For urbanization, three indicators were used: an eight-category variable based on district-level population density (inhabitants/km² ), a dichotomous urban/rural variable, and place of residence (countryside, towns, small cities, or capital/large cities).

RESULTS

The prevalence of DBM was lower in urban than in rural areas (prevalence ratio [PR] 0.70; 95% CI: 0.65-0.75), and compared with the countryside, DBM was less prevalent in towns (PR 0.75; 95% CI: 0.69-0.82), small cities (PR 0.73; 95% CI: 0.67-0.79), and capital/large cities (PR 0.53; 95% CI: 0.46-0.61). Using population density, the adjusted prevalence of DBM was 9.7% (95% CI: 9.4%-10.1%) in low-density settings (1 to 500 inhabitants/km² ), 5.9% (95% CI: 4.9%-6.8%) in mid-urbanized settings (1,001 to 2,500 inhabitants/km² ), 5.8% (95% CI: 4.5%-7.1%) in more densely populated settings (7,501 to 10,000 inhabitants/km² ), and 5.5% (95% CI: 4.1%-7.0%) in high-density settings (>15,000 inhabitants/km² ).

CONCLUSIONS

The prevalence of DBM is higher in the least-urbanized settings such as rural and peri-urban areas, particularly those under 2,500 inhabitants/km² .

Nutrition education improves knowledge and BMI-for-age in Ghanaian school-aged children

BACKGROUND

Adequate nutrition is required for growth and development in children. This study tested the effectiveness of nutrition education on knowledge and BMI-for-age (BFA) of school-aged children in the Kumasi Metropolis.

METHODS

Children, aged 9-13 years old were recruited from ten randomly selected primary schools in the Metropolis. The schools were randomly allocated into 3 groups: nutrition education (3 schools), physical activity (PA) education (3 schools), both interventions (2 schools), or control (2 schools). Following a baseline nutrition and PA knowledge and status assessment in 433 children, twice-monthly nutrition and PA education and demonstrations were carried out for 6 months, followed by a post-intervention assessment.

RESULTS

PA and nutrition knowledge improved in all groups (P<0.001); the highest improvement was among those who received both interventions (31.0%), followed by the nutrition education group (29.8%), and the least, the control group (19.1%). Overall, BFA improved by +0.36, from baseline (-0.26) to end of the intervention (+0.10, P<0.001). Within the groups, the nutrition group (+0.65, P<.001) had the highest improvement, then, both the intervention group (+0.27, P<0.001), the PA group (+0.23, P<0.001) and lastly, the control group (+0.18, P=0.001).

CONCLUSION

Nutrition education could improve knowledge and BMI-for-age in school-aged children in Ghana.

Intraindividual double-burden of anthropometric undernutrition and "metabolic obesity" in Indian children: a paradox that needs action

Background

Intraindividual coexistence of anthropometrically defined undernutrition and “metabolic obesity”, characterised by presence of at least one abnormal cardiometabolic risk factor, is rarely investigated in young children and adolescents, particularly in Low-and-Middle-Income-Countries undergoing rapid nutrition transition.

Methods

Prevalence of biomarkers of metabolic obesity was related to anthropometric and socio-demographic characteristics in 5-19 years old participants from the population-based Comprehensive National Nutrition Survey in India (2016-2018). The biomarkers, serum lipid-profile (total cholesterol (TC), low density lipoprotein (LDL), high density lipoprotein (HDL) and triglycerides), fasting glucose, and glycosylated hemoglobin (HbA1C), and all jointly were analysed in 22567, 23192, 25962 and 19143 participants, respectively.

Results

Overall (entire dataset), the prevalence of abnormalities was low (4.3-4.5%) for LDL and TC, intermediate for dysglycemia (10.9-16.1%), and high for HDL and triglycerides (21.725.8%). Proportions with ≥1 abnormal metabolic obesity biomarker(s) were 56.2% overall, 54.2% in thin (BMI-for-age <-2SD) and 59.3% in stunted (height-for-age <-2SD) participants. Comparable prevalence was evident in mild undernutrition (-1 to -2 SD). Clustering of two borderline abnormalities occurred in one-third, warranting active life-style interventions. Metabolic obesity prevalence increased with BMI-for-age. Among those with metabolic obesity, only 9% were overweight/obese (>1SD BMI-for-age). Among poor participants, triglyceride, glucose and HDL abnormalities were higher.

Conclusions

A paradoxical, counter-intuitive prevalence of metabolic obesity biomarker(s) exists in over half of anthropometrically undernourished and normal-weight Indian children and adolescents. There is a crucial need for commensurate investments to address overnutrition along with undernutrition. Nutritional status should be characterized through additional reliable biomarkers, instead of anthropometry alone.

Factors associated with the double burden of malnutrition at the household level: A scoping review

The double burden of malnutrition (DBM) at the household level has been defined as the coexistence of underweight children and overweight mothers within the same household. The objective of the scoping review was to identify and understand factors associated with DBM. We conducted the scoping review of published, peer-reviewed journal articles in two major databases used in public health research (PubMed and Web of Science). A total of 70 articles met the eligibility criteria. The following factors were identified: mother's age, height, educational level, occupation, food intake, breastfeeding, family income, family size, and urbanization type. Overall, results were heterogeneous. Two scenarios have been identified. The first scenario is those obese women with a job, having a sufficient income, a high educational level, the ability to purchase food, and live either in rural or urban areas. The second scenario is obese women without a job, having an insufficient income, a low educational level, without the ability to purchase food, and live either in rural or urban areas. The DBM at the household level is a complex public health problem. There is a need for target-specific interventions to address child undernutrition and maternal overweight/obesity simultaneously.

Concurrence of stunting and overweight/obesity among children: Evidence from Ethiopia

Background

Nutrition transition in many low- and middle-income countries (LMICs) has led to shift in childhood nutritional outcomes from a predominance of undernutrition to a double burden of under- and overnutrition. Yet, policies that address undernutrition often times do not include overnutrition nor do policies on overweight, obesity reflect the challenges of undernutrition. It is therefore crucial to assess the prevalence and determinants of concurrence stunting and overweight/obesity to better inform nutrition programs in Ethiopia and beyond.

Methods

We analyzed anthropometric, sociodemographic and dietary data of children under five years of age from 2016 Ethiopian Demographic and Health Survey (EDHS). A total of 8,714 children were included in the current study. Concurrence of stunting and overweight/obesity (CSO) prevalence was estimated by basic, underlying and immediate factors. To identify factors associated with CSO, we conducted hierarchical logistic regression analyses.

Results

The overall prevalence of CSO was 1.99% (95% CI, 1.57–2.53). The odds of CSO was significantly higher in children in agrarian region compared to their counter parts in the pastoralist region (AOR = 1.51). Other significant factors included; not having improved toilet facility (AOR = 1.94), being younger than 12 months (AOR = 4.22), not having history of infection (AOR = 1.83) and not having taken deworming tablet within the previous six months (AOR = 1.49).

Conclusion

Our study provided evidence on the co-existence of stunting and overweight/obesity among infants and young children in Ethiopia. Therefore, identifying children at risk of growth flattering and excess weight gain provides nutrition policies and programs in Ethiopia and beyond with an opportunity of earlier interventions through improving sanitation, dietary quality by targeting children under five years of age and those living in Agrarian regions of Ethiopia.

Trends and patterns of the double burden of malnutrition (DBM) in Peru: a pooled analysis of 129,159 mother-child dyads

Background

This study aims to evaluate trends of DBM in Peru over the last 20 years.

Methods

Using individual-level data collected in nationally representative household surveys from Peru between 1996 and 2017, we analysed trends in the prevalence and patterning of the DBM. We classified the nutritional status of children and their mothers as undernourished (either underweight, stunted or wasted for children), normal, overweight or obese. Children classified as experiencing the DBM were those undernourished and living with an overweight or obese mother. We also fitted logistic regression models to evaluate the probability of children having an overweight/obese mother across subgroups of socioeconomic status, place of residence and education.

Results

The overall percentage of children experiencing the DBM in 2016 was 7%, and constitutes ~203,600 children (90% of whom were stunted). Between 1996 and 2016, undernourished children have seen the largest relative increase in the risk of having an overweight mother (31% vs. 37%) or obese mother (6% vs. 17%); however, due to the substantial decrease in the absolute number of undernourished children, the DBM has not grown. Moreover, all children, irrespective of their own nutritional status, are now more likely to live with an overweight or obese mother, a consistent pattern across wealth, location and education subgroups, and all regions of Peru.

Conclusions

DBM prevalence in Peru has decreased, although the number of DBM cases is estimated to be above 200,000. In addition, all children are now more likely to live with overweight or obese mothers. The basic pattern has shifted from one of undernourished children whose mothers have a ‘normal’ BMI, to one where now most children have a ‘normal’ or healthy anthropometric status, but whose mothers are overweight or obese. This suggest that Peru is on the cusp of a major public health challenge requiring significant action.

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.

High double burden of child stunting and maternal overweight in the Republic of the Marshall Islands

Many low‐ and middle‐income countries are faced with a double burden of malnutrition characterized by a stagnating burden of undernutrition and an increasing prevalence of overweight and obesity often observed both at population and household levels. We used data from the 2017 National Integrated Child Health and Nutrition Survey in the Republic of the Marshall Islands to explore the prevalence of overweight mother‐stunted child pairs (mother–child double burden, MCDB). We used bivariate analysis, multivariate logistic regression, and multinomial logistic regression analysis to explore associations between child‐, maternal‐, and household‐level variables and both stunting and MCDB and other types of maternal–child pairs. Our results indicate that nearly three out of four mothers were overweight or obese and one in four households is home to an overweight mother with a stunted child. The risk of child stunting and of MCDB were largely associated with maternal characteristics of lower maternal height, maternal age at birth, years of education, and marital status and household economic status as measured by wealth index and number of household members. These findings support the growing body of evidence showing that the coexistence of high maternal overweight and child stunting (MCDB) has linked root causes to early life undernutrition that are exacerbated by the nutrition transition.

Intraindividual double burden of overweight or obesity and micronutrient deficiencies or anemia among women of reproductive age in 17 population-based surveys

BACKGROUND

Rising prevalence of overweight/obesity (OWOB) alongside persistent micronutrient deficiencies suggests many women face concomitant OWOB and undernutrition.

OBJECTIVES

We aimed to 1) describe the prevalence of the double burden of malnutrition (DBM) among nonpregnant women of reproductive age, defined as intraindividual OWOB and either ≥1 micronutrient deficiency [micronutrient deficiency index (MDI) > 0; DBM-MDI] or anemia (DBM-anemia); 2) test whether the components of the DBM were independent; and 3) identify factors associated with DBM-MDI and DBM-anemia.

METHODS

With data from 17 national surveys spanning low- and middle-income countries (LMICs) and high-income countries from the Biomarkers Reflecting Inflammation and Nutritional Determinants of Anemia project (n = 419 to n = 9029), we tested independence of over- and undernutrition using the Rao-Scott chi-square test and examined predictors of the DBM and its components using logistic regression for each survey.

RESULTS

Median DBM-MDI was 21.9% (range: 1.6%-39.2%); median DBM-anemia was 8.6% (range: 1.0%-18.6%). OWOB and micronutrient deficiencies or anemia were independent in most surveys. Where associations existed, OWOB was negatively associated with micronutrient deficiencies and anemia in LMICs. In 1 high-income country, OWOB women were more likely to experience micronutrient deficiencies and anemia. Age was consistently positively associated with OWOB and the DBM, whereas the associations with other sociodemographic characteristics varied. Higher socioeconomic status tended to be positively associated with OWOB and the DBM in LMICs, whereas in higher-income countries the association was reversed.

CONCLUSIONS

The independence of OWOB and micronutrient deficiencies or anemia within individuals suggests that these forms of over- and undernutrition may have unique etiologies. Decision-makers should still consider the prevalence, consequences, and etiology of the individual components of the DBM as programs move towards double-duty interventions aimed at addressing OWOB and undernutrition simultaneously.

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.

Deforestation and Household- and Individual-Level Double Burden of Malnutrition in Sub-Saharan Africa

Introduction

Although forests and forest-based ecosystems have been shown to influence health and sustainable diets, there is limited evidence on how deforestation affects the current nutrition transition and the double burden of malnutrition. We examined the relationship between deforestation and the individual- and household-level double burden of malnutrition in 15 countries in Sub-Saharan Africa.

Materials and methods

We combined data from geolocated Demographic and Health Surveys and the Global Forest Change dataset. We defined household-level double burden of malnutrition as the co-occurrence of an overweight woman of childbearing age (WCBA) and a stunted pre-school child (PSC) within the same household. We defined individual-level double burden in two ways: 1) as the co-occurrence of overweight and anemia within an individual WCBA, and 2) as the co-occurrence of overweight and stunting within a PSC. We used logistic regression analysis to examine the association between forest cover loss and these three measures after adjusting for potential confounders. We also assessed the mechanisms linking forest cover loss and nutritional status, such as livestock ownership and access to clean water.

Results

In our sample, the prevalence rates of the three measures of the double burden were: overweight and anemic WCBA: 8.4%, overweight WCBA and stunted PSC: 6.9%, overweight and stunted PSC: 2.7%. After adjusting for the confounders as well as country fixed effects and the month of the survey, forest cover loss was marginally associated with a higher odds of an overweight WCBA and stunted PSC (odds ratio (95% CI): 4.80 (0.82, 28.25)). We found no association between forest cover loss and odds of an overweight and stunted PSC (odds ratio (95% CI): 2.47 (0.80, 7.60)) or the odds of an anemic and overweight WCBA (odds ratio (95% CI): 0.71 (0.15, 3.32)).

Discussion

Deforestation does not seem to be an important driver of the double burden of malnutrition in SSA. However, deforestation influences several intermediate factors which, in turn, may influence the double burden. The overall weak association between forest cover loss and double burden measures mask significant heterogeneity across regions within SSA. Future research should unpack the mechanisms behind these regional differences.

Nutritional status of Tajik children and women: Transition towards a double burden of malnutrition

The double burden of malnutrition, an emerging concern in developing countries, can exist at various levels: individual, household, and population. Here, we explore the nutritional status of Tajik women (15-49 years) and children (5-59 months) focusing on overweight/obesity along with undernutrition (underweight, stunting, and micronutrient deficiencies). For this, nutritional markers (haemoglobin (Hb), transferrin receptor (TfR), serum ferritin (Sf), retinol binding protein (RBP), vitamin D, serum folate, and urinary iodine), height, and weight were assessed from 2,145 women and 2,149 children. Dietary intake, weaning, and breastfeeding habits were recorded using a 24-hr recall and a questionnaire. Overweight (24.5%) and obesity (13.0%) are increasing among Tajik women compared with previous national surveys (2003 and 2009). Prevalence of iron deficiency and anaemia was 38.0% and 25.8%, respectively; 64.5% of women were iodine deficient, 46.5% vitamin A deficient, and 20.5% had insufficient folate levels. Women in rural areas had significantly lower iron status and body mass index and higher iodine intake compared with urban areas; 20.9% of children were stunted, 2.8% wasted, 6.2% underweight, 52.4% iron deficient, and 25.8% anaemic; all more prominent in rural areas. Dietary diversity was higher among urban women. Intraindividual or household double burden was not seen. In summary, double burden of malnutrition constituted an increase in overweight among women, especially in urban areas, and persisting levels of undernutrition (stunting, iron, and vitamin A deficiency), predominately in rural areas. A holistic, innovative approach is needed to improve infant and young children feeding and advise mothers to maintain an adequate diet.

Prevalence and factors associated with double and triple burden of malnutrition among mothers and children in Nepal: evidence from 2016 Nepal demographic and health survey

BACKGROUND

Malnutrition in mothers and children is a significant public health challenge in developing countries such as Nepal. Although undernutrition in children has been gradually decreasing, the coexistence of various forms of malnutrition in mothers and children has continued to rise globally. There is a gap in knowledge of the coexistence of such multiple burdens of malnutrition in the Nepalese context. The aims of this study were to explore the coexistence of various forms of malnutrition and associated factors among mother-child pairs residing in the same household.

METHODS

A total sample of 2261 mother-child pairs from the Nepal Demographic and Health Survey (NDHS) 2016 were included in the study. Anthropometric measurements and hemoglobin levels of children and anthropometric measurements of their mothers were collected. Bivariate and multivariable logistic regression models were used to assess the factors associated with the double burden of malnutrition (DBM) and the triple burden of malnutrition (TBM).

RESULTS

Prevalence of DBM and TBM was 6.60% (95% CI: 5.13-8.84) and 7.00% (95% CI: 5.42-8.99) respectively in the same households. In the adjusted multivariable logistic regression models, mothers with short stature (AOR = 4.18, 95% CI: 2.04-8.52), from the richest wealth quintile (AOR = 2.46, 95% CI: 1.17-5.15), aged over 35 years (AOR = 3.08, 95% CI: 1.20-7.86), and those who had achieved at least secondary level education (AOR = 2.05, 95% CI: 1.03-4.07) were more likely to suffer from the DBM. Similarly, mothers with short stature (AOR = 5.01, 95% CI: 2.45-10.24), from the richest wealth quintile (AOR = 2.66, 95% CI: 1.28-5.54), aged over 35 years (AOR = 3.41, 95% CI: 1.26-9.17), and those who had achieved at least secondary level education (AOR = 2.05, 95% CI: 1.00-4.18) were more likely to suffer from the TBM.

CONCLUSIONS

Overall, there is a low prevalence of double and triple burden of malnutrition among mother-child pairs in Nepal. Older mothers with short stature and those from richer wealth quintiles were more likely to suffer from double and triple burden of malnutrition.

Underweight, body image, and weight loss measures among adolescents in Saudi Arabia: is it a fad or is there more going on?

Background and Objective

Adolescence is considered to be a pivotal point in which optimum nutrition and eating habits are developed. Although tackling the obesity epidemic has been much discussed, addressing the issue of underweight and body image is often neglected. This study was carried out to get a better understanding of underweight status among adolescents in Saudi Arabia, and exploring self-perceptions of body image and weight loss measures among underweight adolescents.

Methods

Data from Jeeluna®, a national cross-sectional school-based survey were utilized. Jeeluna® assessed the health status and health-risk behaviors of adolescents in school through data obtained by a self-administered questionnaire, anthropologic measurements, and laboratory investigations.

Results

A total of 12,463 adolescents participated. Eighteen percent of adolescent males and 12.4% of females were found to be underweight, representing 14.9% of adolescents collectively. Forty-five percent of underweight participants were happy with their weight. Underweight females between the age group of 10 and 14 years were the most likely to believe that they still need to lose weight (16.0%) followed by females aged 15–19 years (9.7%). Underweight females aged 10–14 years were also the group most likely to engage in purging (1.6%). Stepwise logistic regression found that the strongest association with being underweight was with having a lower household income (OR 2.0, CI 1.5–2.7) and having more than 5 siblings (OR 1.8, CI 1.5–2.3).

Conclusion

Underweight status is prevalent among adolescents in Saudi Arabia and deserves more attention as a public health issue. Distorted body image and disordered eating behaviors exist, necessitating further investigation of underlying causes.

Water, food, and the dual burden of disease in Galápagos, Ecuador

OBJECTIVE

Rapid development in low- and middle-income countries (LMIC) has led to changes in diet that have outpaced water and sanitation improvements, contributing to a dual burden of overweight and noncommunicable disease risk factors (OWT/NCD) and undernutrition and infectious disease symptoms (UND/ID) within individuals and households. Yet, little work has examined the joint impact of water and food exposures on the development of the dual burden.

METHODS

We use data from Ecuador's nationally representative Encuesta Nacional de Salud y Nutrición (ENSANUT-ECU) to test whether water access and quality and diet quality and security are associated with OWT/NCD and UND/ID among 1119 children and 1582 adults in Galápagos. Adjusted multinomial and logistic models were used to test the separate and joint associations between water and food exposures and the dual burden and its components at the individual and household levels.

RESULTS

The prevalence of the dual burden of OWT/NCD and UND/ID was 16% in children, 33% in adults, and 90% in households. Diet quality was associated with a higher risk of dual burden in individuals and households. Mild food insecurity was positively associated with the risk of dual burden at the household level. No water variable separately predicted the dual burden. Joint exposure to poor water access and food insecurity was associated with greater odds of dual burden in households.

CONCLUSION

Our results suggest that unhealthy diets and poor water quality contribute to the dual burden at the individual and household levels. Addressing both food and water limitations is important in LMIC.

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.

Various forms of double burden of malnutrition problems exist in rural Kenya

BACKGROUND

The coexistence of overweight/obesity and undernutrition is often referred to as the double burden of malnutrition (DB). DB was shown to exist in many developing countries, especially in urban areas. Much less is known about DB in rural areas of developing countries. Also, the exact definition of DB varies between studies, making comparison difficult. The objective of this study is to analyse DB problems in rural Kenya, using and comparing different DB definitions and measurement approaches.

METHODS

Food intake and anthropometric data were collected from 874 male and female adults and 184 children (< 5 years) through a cross-section survey in rural areas of Western Kenya. DB at the individual level is defined as a person suffering simultaneously from overweight/obesity and micronutrient deficiency or stunting. DB at the household level is defined as an overweight/obese adult and an undernourished child living in the same household, using underweight, stunting, wasting, and micronutrient deficiency as indicators of child undernutrition.

RESULTS

DB at the individual level is found in 19% of the adults, but only in 1% of the children. DB at the household level is relatively low (1-3%) when using wasting or underweight as indicators of child undernutrition, but much higher (13-17%) when using stunting or micronutrient deficiency as indicators.

CONCLUSION

Various forms of DB problems exist in rural Kenya at household and individual levels. Prevalence rates depend on how exactly DB is defined and measured. The rise of overweight and obesity, even in rural areas, and their coexistence with different forms of undernutrition are challenges for food and nutrition policies.

Challenges and opportunities to tackle the rising prevalence of diet-related non-communicable diseases in Africa

Africa is experiencing a sharp rise in non-communicable diseases (NCD) related to rapid globalisation and urbanisation leading to shifts in dietary and lifestyle patterns characterised by increased energy intake and physical inactivity. However, unlike more resource-endowed regions, Africa has a double burden of disease: NCD co-exist with infectious diseases including lower respiratory tract infections, HIV/AIDS and diarrhoeal diseases. The African economy is also relatively weaker, making it difficult to cope with this burden. It is postulated that NCD will soon overtake infectious diseases as the number one cause of death in the African region. The recognition of NCD as diseases and obesity as a related risk factor is weak in Africa, compounded by stigma associated with wasting in HIV/AIDS and obesity being perceived as a sign of wealth, achievement and care. There is also a dearth of data on overweight and obesity in the region and little knowledge that infant feeding practices, such as breast-feeding, are linked to reduced risk of NCD in both children and mothers. While complex multi-sectoral approaches to address this NCD menace are needed, Africa may benefit from taking simple initial steps to address NCD risk factors including: (1) behaviour change communication to challenge perceptions on NCD; (2) promoting and protecting breast-feeding; (3) formulating policies and regulations limiting wide availability of unhealthy foods; (4) mainstream nutrition education in school curricula and (5) collection of accurate data based on indicators that can reflect the double burden of disease and malnutrition; and fostering multi-sectoral actions against NCD.

Prevalence and sociodemographic determinants of household-level double burden of malnutrition in Bangladesh

OBJECTIVE

To investigate the prevalence and sociodemographic determinants of household-level mother-child double burden (MCDB) of malnutrition in Bangladesh.

DESIGN

The analysis was done using Bangladesh Demographic and Health Survey 2014 data. Multivariable logistic regression identified the sociodemographic factors associated with double-burden households.

SETTING

Nationally representative cross-sectional survey.ParticipantsA total of 5951 households were included in the analysis.

RESULTS

A coexistence of overweight or obese mother and underweight or stunted or wasted child (OWOBM/USWC) was found in 6·3 % households. The prevalence of overweight or obese mother and underweight child (OWOBM/UWC) was 3·8 %, of overweight or obese mother and stunted child (OWOBM/STC) was 4·7 %, and of overweight or obese mother and wasted child (OWOBM/WSC) was 1·7 %. Mother's age 21-25 years at first birth, middle wealth index group, having two or three children and having four or more children showed statistically significant (P&lt;0·05) associations with OWOBM/UWC. Households with mother's age 21-25 years at first birth, middle wealth index group, no exposure to information media, having two or three children and having four or more children had higher odds of OWOBM/STC and OWOBM/USWC which were statistically significant (P&lt;0·05). Delivery of child through caesarean section was significantly associated with OWOBM/USWC (P&lt;0·05).

CONCLUSIONS

Although the prevalence of MCDB of malnutrition in Bangladesh is low, prevention programmes must consider the nutrition concerns of the entire household to prevent future risks. Such programmes also need to be tagged with family planning and increasing awareness through social and behaviour change counselling and exposure to information media.

Trends of mortality attributable to child and maternal undernutrition, overweight/obesity and dietary risk factors of non-communicable diseases in sub-Saharan Africa, 1990-2015: findings from the Global Burden of Disease Study 2015

OBJECTIVE

To assess trends of mortality attributable to child and maternal undernutrition (CMU), overweight/obesity and dietary risks of non-communicable diseases (NCD) in sub-Saharan Africa (SSA) using data from the Global Burden of Disease (GBD) Study 2015.

DESIGN

For each risk factor, a systematic review of data was used to compute the exposure level and the effect size. A Bayesian hierarchical meta-regression analysis was used to estimate the exposure level of the risk factors by age, sex, geography and year. The burden of all-cause mortality attributable to CMU, fourteen dietary risk factors (eight diets, five nutrients and fibre intake) and overweight/obesity was estimated.

SETTING

Sub-Saharan Africa.ParticipantsAll age groups and both sexes.

RESULTS

In 2015, CMU, overweight/obesity and dietary risks of NCD accounted for 826204 (95 % uncertainty interval (UI) 737346, 923789), 266768 (95 % UI 189051, 353096) and 558578 (95 % UI 453433, 680197) deaths, respectively, representing 10·3 % (95 % UI 9·1, 11·6 %), 3·3 % (95 % UI 2·4, 4·4 %) and 7·0 % (95 % UI 5·8, 8·3 %) of all-cause mortality. While the age-standardized proportion of all-cause mortality accounted for by CMU decreased by 55·2 % between 1990 and 2015 in SSA, it increased by 63·3 and 17·2 % for overweight/obesity and dietary risks of NCD, respectively.

CONCLUSIONS

The increasing burden of diet- and obesity-related diseases and the reduction of mortality attributable to CMU indicate that SSA is undergoing a rapid nutritional transition. To tackle the impact in SSA, interventions and international development agendas should also target dietary risks associated with NCD and overweight/obesity.

Burden of disease attributable to suboptimal diet, metabolic risks and low physical activity in Ethiopia and comparison with Eastern sub-Saharan African countries, 1990-2015: findings from the Global Burden of Disease Study 2015

BACKGROUND

Twelve of the 17 Sustainable Development Goals (SDGs) are related to malnutrition (both under- and overnutrition), other behavioral, and metabolic risk factors. However, comparative evidence on the impact of behavioral and metabolic risk factors on disease burden is limited in sub-Saharan Africa (SSA), including Ethiopia. Using data from the Global Burden of Disease (GBD) Study, we assessed mortality and disability-adjusted life years (DALYs) attributable to child and maternal undernutrition (CMU), dietary risks, metabolic risks and low physical activity for Ethiopia. The results were compared with 14 other Eastern SSA countries.

METHODS

Databases from GBD 2015, that consist of data from 1990 to 2015, were used. A comparative risk assessment approach was utilized to estimate the burden of disease attributable to CMU, dietary risks, metabolic risks and low physical activity. Exposure levels of the risk factors were estimated using spatiotemporal Gaussian process regression (ST-GPR) and Bayesian meta-regression models.

RESULTS

In 2015, there were 58,783 [95% uncertainty interval (UI): 43,653-76,020] or 8.9% [95% UI: 6.1-12.5] estimated all-cause deaths attributable to CMU, 66,269 [95% UI: 39,367-106,512] or 9.7% [95% UI: 7.4-12.3] to dietary risks, 105,057 [95% UI: 66,167-157,071] or 15.4% [95% UI: 12.8-17.6] to metabolic risks and 5808 [95% UI: 3449-9359] or 0.9% [95% UI: 0.6-1.1] to low physical activity in Ethiopia. While the age-adjusted proportion of all-cause mortality attributable to CMU decreased significantly between 1990 and 2015, it increased from 10.8% [95% UI: 8.8-13.3] to 14.5% [95% UI: 11.7-18.0] for dietary risks and from 17.0% [95% UI: 15.4-18.7] to 24.2% [95% UI: 22.2-26.1] for metabolic risks. In 2015, Ethiopia ranked among the top four countries (of 15 Eastern SSA countries) in terms of mortality and DALYs based on the age-standardized proportion of disease attributable to dietary and metabolic risks.

CONCLUSIONS

In Ethiopia, while there was a decline in mortality and DALYs attributable to CMU over the last two and half decades, the burden attributable to dietary and metabolic risks have increased during the same period. Lifestyle and metabolic risks of NCDs require more attention by the primary health care system of the country.