the ‘household’ double burden of malnutrition
DESCRIPTION
Katherine Bates (LSE) S.V. Subramanian (HSPH). The ‘Household’ 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 - PowerPoint PPT PresentationTRANSCRIPT
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)