The double burden household in sub-Saharan Africa: maternal overweight and obesity and childhood undernutrition from the year 2000: results from World Health Organization Data (WHO) and Demographic Health Surveys (DHS)

BMC Public Health The double burden household in sub-Saharan Africa: maternal overweight and obesity and childhood undernutrition from the year 2000: results from World Health Organization Data (WHO) and Demographic Health Surveys (DHS) Janet M Wojcicki 0 0 Department of Pediatrics, University of California , 500 Parnassus Avenue MU4E, San Francisco, CA 94134-0136 , USA Background: Previous studies have characterized an increasing trend of double burden households, or households with individuals experiencing both undernutrition and obesity, in countries undergoing a nutrition transition. Although most prior studies indicate the prevalence of double burden households is highest in middle-income countries, there is some support for an increase in double burden households in sub-Saharan African countries as well. Method: Using data from the Demographic Health Surveys (DHS) and the World Health Organization (WHO), the prevalence of double burden households in sub-Saharan African countries was calculated and the associations between prevalence of overweight/obese adults and underweight, stunted and wasted children were evaluated at the country and household (DHS only) levels. Restricted analyses and frequencies were calculated using urban-only datasets. Surveys from 28 African countries were available using WHO data and 26 from the DHS surveys. Only surveys that were conducted after 2000 were included in analyses. Results: Using the WHO datasets, there were inverse associations between the prevalence of overweight and obesity in adults and underweight, stunting and wasting in children. Correspondingly, there were positive associations between adult underweight and child underweight, stunting and wasting. These associations were not significant in a smaller sample size using urban-only surveys. The prevalence of double burden households in DHS datasets was low: under 5 percent for obese mothers and underweight, stunted or wasted child pairs with a slightly higher percentage for overweight mothers and children with undernutrition. Restricting the analysis to urban only populations did not increase the frequencies of double burden households significantly. Conclusion: There was a low prevalence of double burden households in recent data from sub-Saharan Africa. Countries that have a high prevalence of child undernutrition correspondingly have a high prevalence of adult underweight and low prevalence of adult overweight and obesity. - Background Overweight and obesity and malnutrition globally The number of overweight and obese women has continued to increase internationally including in low-income countries such as those in sub-Saharan Africa [1]. Meanwhile, undernutrition is associated with one third to one half of the deaths of children under 5 years of age globally [2]. In sub-Saharan Africa, 28% of children under 5 years of age are moderately or severely underweight [3] with 38% of children under five stunted [4]. These numbers have not significantly changed since 1990 when 32% of children under 5 were moderately or severely stunted [4]. Meanwhile global obesity prevalence has doubled since 1980 [1]. In a study of 7 African countries (Burkina Faso, Ghana, Kenya, Malawi, Niger, Senegal and Tanzania), the prevalence of urban adult overweight and obesity increased approximately 35% from 1992 to 2005 [5]. Similarly, the prevalence of overweight and obesity among preschool children is expected to increase from 8.5% in 2010 to 12.7% in 2020 [6]. Double -burden households Recent studies have found an increasing trend of dual burden or double burden households, households that have both underweight or stunted and overweight/obese persons [7,8]. In particular, countries that are in the middle range of gross national product (GNP) have been found to have the highest prevalence of dual burden homes, most commonly with stunting and/or underweight among children coexisting with an overweight or obese mother [7,8]. In studies conducted in Brazil, China, Indonesia, United States and Vietnam, dual burden households were more likely to be urban and among the highest income levels in contrast with underweight-only households. However, double burden homes were not easily distinguished from overweight-only households [7]. The nutrition transition, a change in activity levels and dietary patterns that happens when a country passes to higher levels of economic development facilitating the availability of cheaper energy dense and nutrient poor food stuffs, could be responsible for the co-existence of obesity and undernutrition in the same homes [8-10]. Meanwhile, however, some studies from sub-Saharan Africa have found a low prevalence of double burden households [8-10]. In a report of data from the Demographic and Health surveys of 23 sub-Saharan African countries, African countries surveyed had less than 10% of households with stunted child-overweight mother pairs with the exception of Egypt, which had 14% [9]. A study from urban Benin (Cotonou), found a higher prevalence (16.2%) of households with concurrent maternal overweight/obesity and child stunting or child wasting [10]. Meanwhile, the majority of the Demographic and Health surveys in the study by Garrett and Ruel [9] were from the period of 1991-1998. It is possible that in the last 10-20 years, the prevalence of double burden households has increased significantly in sub-Saharan African countries, particularly in urban areas that have had more of a nutrition transition. The prevalence of stunted child-overweight mothers was higher in urban African areas in comparison with rural ones because of the fewer number of women who are overweight/obese in rural areas [9]. In a more recent study using Demographic Health Survey data from the early 2000s from North Africa, sub-Saharan Africa, Asia and Latin America, Jehn and Brewis [8] found that low levels of maternal education, working in agriculture, living in urban areas, increased siblings in the household and relative poverty were associated with increased risk of dual burden households. However, Jehn and Brewis [8] found that the overall prevalence of dual burden households was low in the African countries surveyed, particularly the prevalence of maternal overweight and child underweight homes (<5% of households). Jehn and Brewis [8] examined only a limited number of surveys from sub-Saharan African countries and used data collected in the early 2000s. Since the time of publication, DHS has released a new series of surveys (DHS V); many conducted post 2005 that are included in the analysis below. In this review of double burden households in subSaharan Africa, we assess both the association between maternal body mass index (BMI) category and child undernutrition using country level data (World Health Organization Survey Data from the Nutrition Databases) and the prevalence of double burden households using household level data as described below (DHS data). In contrast with prev (...truncated)