The ‘Household’ Double Burden of Malnutrition

Katherine Bates (LSE) S.V. Subramanian (HSPH)

Introduction to the Double Burden of Malnutrition• Nutrition Transition ‘altered trajectory’

⁻ Rapid socioeconomic development and urbanisation⁻ Leading to changing behaviours

• Parallels with epidemiological transition & double burden of disease

⁻ ‘Modernisation complex’ (Omran 1971)

• Leading to multifaceted burdens of malnutrition the ‘double’ or ‘dual’ burdens of malnutrition

• Use of anthropometric indicators to define ‘burdens’⁻ Children – height-for-age (stunted), weight-for-height

(wasted/overweight)⁻ Adults – BMI

• At different levels –population level, community level, household level, individual level (e.g. stunted-overweight children, adults high BMI short stature)

• Within demographic groups (e.g. DBM adults at the population level)

• Across demographic groups (e.g. mother/child)

The ‘household’ level DBM

• Focus of this study : ‘household’ level - mother/child

• Specifically the determinants of an overweight mother’s among stunted children

⁻ HHDBM ‘household double burden of malnutrition’⁻ SCOWT pairs – stunted child overweight mother⁻ MCDB – Maternal and child double burden

⁻ And what distinguishes these stunted children from their peers whose mothers either have a low BMI, or a healthy BMI

Stunted Children and Mothers BMI across Countries

Jordan

Albania

Honduras

Azerbaij

Bolivia

Sao To

me

Burkina

Uganda

Sierra

L

Cambodia

Lesotho

Ethiopia

Mozambiq

Rwanda

Timor-L

e0%

10%

20%

30%

40%

50%

60%

Stunted, Over Stunted, Under Stunted, Normal

Stunted Children and Mothers BMI by GNI

0% 5% 10% 15% 20% 25% 30% 35% 40%0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Stunted, Under Linear (Stunted, Under)Stunted, Over Linear (Stunted, Over)

AzerbaijanJordan

Lesotho

Bolivia

Albania

Timor Leste

Swaziland

Honduras

Stunted Children and Mothers BMI by % Urban

0% 5% 10% 15% 20% 25% 30% 35% 40%0

10

20

30

40

50

60

70

80

90

Stunted, Normal Linear (Stunted, Normal)Stunted Under Linear (Stunted Under)

Benin

Bangladesh

Jordan

Sao Tome e Principe

Lesotho

Bolivia

Mali

Albania

Timor LesteGuyana

Aim of study

• What determines the HHDBM among stunted children?

⁻ Prenatal hypotheses:

⁻ Foetal origins of adult disease (FOAD)

⁻ Postnatal hypotheses:

⁻ Intrahousehold Behaviours⁻ Dietary Quality

Methodology

• Data: Demographic and Health Surveys, Phase-V & Phase-VI 2005-2012 with anthropometric data & biomarkers for currently living children 6 months to 4 years of age among women of reproductive age not currently pregnant (29 countries), country level variables from World Bank Data Catalog

• Sample: n=33325 • 70.9% stunted child, normal BMI mother (23627)• 13.41% stunted child, low BMI mother (4469)• 15.69% stunted child, high BMI mother (5228)

• Dependent variable (multinomial): • Stunted child, normal BMI mother ==0• Stunted child, low BMI mother==1• Stunted child, high BMI mother==2

• Independent variables• FOAD: maternal height• Dietary quality: maternal anaemia• Covariates -child characteristics: age, sex, size at birth; maternal

factors: age, parity; socioeconomic variables: maternal education, wealth, urban; country level variables: % population urban, GNI pc

• Random Intercept Model

Stunted, Under vs. Stunted, normal

Stunted, Over vs Stunted, Normal

Size at birth ref: average

small 1.103* 0.897** large 0.836*** 1.138***

Education ref: none

primary 0.931 1.258***secondary 0.959 1.413***

tertiary 0.583 1.342* Child age (months)   0.996*** 1.003**

Maternal Height (cm)   1.003*** 0.998***

Maternal Anaemia   1.122** 0.948

Maternal Age

20-24 0.836* 1.230* 25-29 0.825* 1.652***30-34 0.948 2.015***35-39 0.996 2.174***40-44 0.984 2.405***45-49 1.394* 2.730***

Urban   1.003 1.220***No. HH members   0.995 0.989*

Wealth ref: poorest

poorer 0.896* 1.324***middle 0.840*** 1.579***richer 0.823*** 2.040***richest 0.666*** 3.659***

Parity: ref 2 to 4 primi 0.95 0.902>=4 0.862** 1.125**

Female   0.946 1.007GNI pc   1.000 1.001**

% Urban pop   0.979* 1.019* cons_1   0.005*** 1.084

Res

ults

Discussion

• At present the analysis has not provided any indication that, among stunted child, overweight mother pairs, there is an energy dense, nutrient poor diet

• Overweight mothers of stunted children are shorter than those with a normal BMI, which supports the FOAD hypothesis

• High birthweight among stunted children with overweight mothers further supports the role of maternal factors and intrauterine environment in determining at dual burden among mother and child

• Evidence for increased prevalence of stunted child, overweight mothers with greater urbanisation and economic development, maternal education and wealth support the role of the ‘modernisation complex’ in determining a dual burden through behavioural change

• Extension of analysis to further explore prenatal/postnatal determinants

A further caveat…

The nutritional profile of stunted children varies, StuntedStunted & wastedStunted overweight

Does this, and in particular, the individual level DBM affect our understanding of the HHDBM?

Child stunted profiles for under-fives with overweight mothers by country (%)

-10%

0%

10%

20%

30%

40%

50%

60%

stuntwas stuntove stunted

0% 5% 10% 15% 20%0

1000

2000

3000

4000

5000

6000

7000

8000

9000

Stunted Linear (Stunted)Stunted & Overweight Linear (Stunted & Overweight)Stunted & Wasted Linear (Stunted & Wasted)

GN

I pc

PPP

(C

urrn

ent

US$

)

Egypt

GNI per capita and % Stunted Children with Overweight Mothers

Albania

Maldives

0% 5% 10% 15% 20%10

20

30

40

50

60

70

80

90

Stunted Linear (Stunted) Stunted & OverweightLinear (Stunted & Overweight) Stunted & Wasted Linear (Stunted & Wasted)

% Urban Population and % Children with Overweight Mothers by Stunting Profile

Egypt

Jordan

Albania

Results - Multinomial

Fixed Effect for Country - ref

Stunted

Stunted &

OverweightStunted &

WastedSize at birth ref: average

small 0.745*** 1.374*large 1.370*** 0.864

Child age (months) 0.985*** 0.987***Female   1.237*** 0.838***

Parity: ref 2 to 4 primi 0.903 0.98high 0.921 0.825

Maternal Height (cm) 1.002*** 0.999

Maternal Age

20-24 0.786 0.9925-29 0.776 1.04430-34 0.77 1.09535-39 0.778 1.25940-44 0.729 0.81845-49 0.729 1.094

Education ref: none

primary 1.06 0.925secondary 1.223* 0.943

tertiary 1.305* 0.754

Wealth ref: poorest

poorer 1.286** 0.88middle 1.394*** 1.046richer 1.333** 0.807richest 1.393** 0.837

HH size   0.966*** 1.029*Urban   0.964 0.967GNI pc   1.001*** 0.999Urban

Population %   0.766* 1.98Constant   72.762 0.000***

• p<0.05, ** p<0.01, *** p<0.001

• N 12329

Discussion

• Results suggest different maternal factors are important

• Intrauterine environment leading to large size at birth• Taller mothers

• Socioeconomic gradient in both education and wealth compared to stunted children, the children are from smaller households and live in countries with a greater GNI pc (yet less urbanised)

• Sex differentials - female

• The stunted & wasted are more similar ‘only’ stunted children with•

• They are smaller at birth and younger, from larger households.• The sex difference shows they are more likely male

• Across all groups the effect of maternal age remains significant, with increasing risk of a DBM,

• There are no urban/rural differences across the three groups

For the stunted-overweight:

Future

• Disaggregation of ‘stunted child, overweight mother’ pairs

• Understand biological and behavioural determinants within this group

Funded by the Agnes Metcalfe Studentship for Women (LSE)