Determinants of stunting, underweight and wasting among children < 5 years of age: evidence from 2012-2013 Pakistan demographic and health survey

Khan et al. BMC Public Health (2019) 19:358 https://doi.org/10.1186/s12889-019-6688-2 RESEARCH ARTICLE Open Access Determinants of stunting, underweight and wasting among children < 5 years of age: evidence from 2012-2013 Pakistan demographic and health survey Sadaf Khan1,2*, Sidra Zaheer3 and Nilofer Fatimi Safdar3 Abstract Background: Childhood malnutrition is a critical public health concern in Pakistan. We aimed to explore factors associated with malnutrition in Pakistani children (< 5 years of age) using the Pakistan Demographic and Health Survey (PDHS) 2012–2013. Methods: Sample of 3071 Pakistani children aged 0–59 months from the PDHS 2012–2013, with complete anthropometric measurements were included in the study. Nutritional status was evaluated using anthropometric indices; height-for-age, weight-for-height and weight-for-age, as proxy measures of three forms of under-five malnutrition including stunting, wasting and underweight respectively. Uni- and multivariate binary logistic regressions were used to examine the association between selected maternal-socio-demographic and child level variables (such as child sex, age, size at birth, antenatal clinic visits, recent diarrheal incidence and breastfeeding status) and three proxy measures of child nutritional status. Results: About 44.4% of under-five children were stunted, 29.4% were underweight and 10.7% were wasted. Children whose mothers lived in rural areas (aOR = 0.67, 95%CI 0.48–0.92), were aged ≥18 years at marriage (aOR = 0.76, 95%CI 0.59–0.99) and had visited antenatal clinic more than 3 times during pregnancy (aOR = 0.61, 95%CI 0.38–0.98) were less likely to be stunted. Mother’s low educational level (aOR = 2.55, 95%CI 1.26–5.17), short stature (aOR = 2.31, 95%CI 1.34– 3.98), child’s small size at birth (aOR = 1.67, 95%CI 1.14–2.45) and mother’s BMI were significantly associated with child’s underweight status. Children whose mothers had no education were more likely to be wasted (aOR = 3.61, 95%CI 1.33–9.82). Conclusion: The study suggests that most of the analysed factors that accounted for malnutrition in Pakistani children (such as mother’s age at marriage, educational level and mothers’ nutritional status) are preventable. Therefore, to reduce the burden of malnutrition interventions that can address these factors are required such as community based education and targeted nutritional interventions. Keywords: Malnutrition, Stunting, Wasting, Underweight, Children * Correspondence: 1 Department of Biochemistry, Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan 2 Dow Research Institute of Biotechnology and Biomedical Sciences, Dow University of Health Sciences, Karachi, Pakistan Full list of author information is available at the end of the article © The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Khan et al. BMC Public Health (2019) 19:358 Background Malnutrition remains a critical public health problem among children under the age of five years in developing countries including Pakistan. Malnutrition is caused by multiple interlinked factors and has both short and long term detrimental health effects [1, 2]. It affects the cognitive and physical development of children, increases the risk of infections and significantly contributes to the child’s morbidity and mortality [3, 4]. Stunting, wasting and underweight are three widely recognized indicators of child's nutritional status [5]. While stunting and wasting indicates chronic and acute malnutrition respectively, underweight is a composite indicator and includes both acute (wasting) and chronic (stunting) malnutrition [5]. However, different forms of malnutrition can also occur concurrently in children [6]. Malnutrition significantly contributes to the global burden of several diseases. Globally, undernutrition accounts for at least half of all the deaths annually in children under five [7]. In 2016, according to World Health Organization (WHO), at least 155, 52 and 99 million children under the age of five years were stunted, wasted and underweight worldwide respectively [8, 9]. In addition, around 6 million children were reported with stunting and wasting simultaneously [6]. Malnutrition is clustered in developing countries, particularly in Africa and South Asia [9, 10]. In South Asia, three countries of the region, India, Pakistan and Bangladesh, have particularly high prevalence of the condition [11]. In Pakistan, malnutrition is the major contributor of morbidity and mortality in children under five years of age, and the country ranks 22nd in the world for under-five child mortality [12, 13]. The 2011 national nutrition survey reported that 44% of under-five children in Pakistan were stunted, 15% were wasted and 31% were underweight [14]. The high magnitude of all three indicators of malnutrition in country reflects the poor nutritional and health status among under-fives in country, thus necessitating the need to conduct this study to explore factors associated with malnutrition in Pakistani children. There are multiple factors that contribute to childhood malnutrition. The common determinants reported by several studies include socioeconomic inequalities, geographical differences, suboptimal feeding practices, household food insecurity, maternal literacy and childhood morbidities [15–19]. Previous studies that have been conducted on childhood malnutrition in Pakistan were mostly based on hospital, schools, regional and community settings [20–23]. Limited studies, that have reported the national level data, were either restricted to socio-demographic determinants or children less than two years of age [24, 25]. In addition, there is a paucity of literature regarding the correlates of all three indicators of childhood malnutrition Page 2 of 15 in the country based on nationally representative data set. Therefore, the current study utilized the nationally representative Pakistan Demographic and Health Survey (PDHS) 2012–2013 data, to examine the factors associated with malnutrition among Pakistani children aged 0–59 months. Methods Study design Cross-sectional. Data set Secondary analysis of the PDHS 2012–2013 data set was carried out. The PDHS 2012–2013 was a nationally representative third survey conducted by the National Institute of Population Studies (NIPS), Pakistan, as a part of the international MEASURE DHS (Demographic and Health S (...truncated)