And Overnutrition Among Children and Mothers in Bangladesh: a Spatial Modelling Approach to a Nationally Representative Survey
Total Page：16
File Type：pdf, Size：1020Kb
Public Health Nutrition: 21(13), 2471–2481 doi:10.1017/S1368980018000988 Sociodemographic and geographical inequalities in under- and overnutrition among children and mothers in Bangladesh: a spatial modelling approach to a nationally representative survey Mohammad Nahid Mia1,*, M Shafiqur Rahman2 and Paritosh K Roy2 1Health Systems and Population Studies Division, International Centre for Diarrhoeal Disease Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sarani, Mohakhali, Dhaka 1212, Bangladesh: 2Institute of Statistical Research and Training, University of Dhaka, Dhaka, Bangladesh Submitted 25 July 2017: Final revision received 4 March 2018: Accepted 21 March 2018; First published online 2 May 2018 Abstract Objective: To investigate the sociodemographic and geographical variation in under- and overnutrition prevalence among children and mothers. Design: Data from the 2014 Bangladesh Demographic and Health Survey were analysed. Stunting and wasting for children and BMI < 18·5kg/m2 for mothers were considered as undernutrition; overweight was considered as overnutrition for both children and mothers. We estimated the prevalence and performed simple logistic regression analyses to assess the associations between outcome variables and predictors. Bayesian spatial models were applied to estimate region-level prevalence to identify the regions (districts) prone to under- and overnutrition. Settings/Subjects: Children aged < 5 years and their mothers aged 15–49 years in Bangladesh. Results: A significant difference (P < 0·001) was observed in both under- and overnutrition prevalence between poor and rich. A notable regional variation was also observed in under- and overnutrition prevalence. Stunting prevalence ranged from 20·3 % in Jessore to 56·2 % in Sunamgonj, wasting from 10·6 % in Dhaka to 19·2 % in Bhola, and overweight from 0·8 % in Shariatpur to 2·6 % in Dhaka. Of the sixty-four districts, twelve had prevalence of stunting and thirty-two districts had prevalence of wasting higher than the WHO critical threshold levels. Similarly, fifty-three districts had prevalence of maternal underweight higher than the national level. In contrast, the prevalence of overweight was comparatively high in the industrially equipped metropolitan districts. Keywords Conclusions: Observed sociodemographic and geographical inequalities imply Under- and overnutrition slow progress in the overall improvement of both under- and overnutrition. Bayesian spatial model Therefore, effective intervention programmes and policies need to be designed Mapping urgently targeting the grass-roots level of such regions. Bangladesh Undernutrition is a serious public health problem with Bangladesh, in comparison with slow progress in – important consequences for survival, cognitive develop- sub-Saharan Africa(8 10). Similarly, overnutrition (over- – ment and optimum physical growth(1 3). It is also con- weight or obesity) is also a public health concern because sidered one of the causes of non-communicable diseases, overweight children are at greater risk of developing many morbidity, and decreased economic productivity and health problems, like overweight adults, such as heart earning potential(1,4,5). These problems tend to be severe disease, respiratory illness and type 2 diabetes(11). More- among children younger than 5 years and women of over, overnutrition has a negative effect on children’s reproductive age, particularly in developing countries social and emotional well-being and self-esteem, resulting struggling to emerge from the scourge of extreme in impaired social development. poverty(6). Undernutrition causes 3·1 million child deaths Bangladesh has been commended worldwide for its annually, accounting for 45 % of total child deaths in recent gains in health and nutrition. The prevalence of 2011(1,7). Although the global prevalence of undernutrition childhood stunting (low height-for-age) and under- is continuing to reduce in both children and women, most weight (low weight-for-age) has decreased from 63 and progress has been made in South-East Asia including 62 % in 1990 to 42 and 32 % in 2013, respectively(12). *Corresponding author: Email [email protected] © The Authors 2018 Downloaded from https://www.cambridge.org/core. 26 Sep 2021 at 17:04:06, subject to the Cambridge Core terms of use. 2472 MN Mia et al. The prevalence appears to be lower than in Pakistan district (n 64), upazila (n 489)/thana (n 631) and union (which had stunting and underweight prevalence of 45 (n 4553)(27). Notwithstanding the recent robust annual and 32·6 %, respectively, in 2012), but still higher than in growth in gross domestic product, averaging 6 % per India (39 and 29 %, respectively, in 2014)(12). Despite more annum between 2011 and 2013(31), the country remains than a decade of intervention and great socio-economic one of the poorest in the world with 32 % (rural 52 %, development, however, Bangladesh still has a large urban 22 %) of the population living below the poverty number of children with stunting (6 million) and wasting line of $US 1·25 per day(27). The country has characteristics (2·4 million)(13). In the review of the Millennium Devel- similar to a typical developing nation with high unem- opment Goals, the country was criticized for not focusing ployment rate (29 %) and highly skewed income on nutrition issues appropriately and it failed to achieve inequality(27,32). Twenty per cent of the richest among the the Millennium Development Goal 1 target of child population owns about 42 % of the wealth, while the underweight prevalence of 31 % by 2015(14,15). Similarly, poorest 20 % of the population owns 9 % of the wealth(33). the prevalence of women with underweight (BMI Besides, the distribution of rich and poor is not the same for < 18·5 kg/m2) has decreased from 53 % in 1996 to 19 % in all regions of the country as a majority of rich people live in 2014. However, the rate is not lower than those of urban areas in comparison with their rural counterparts(33). neighbouring countries, such as India, Nepal and Bangladesh is unique among low- and middle-income Pakistan(12). In developing countries like Bangladesh, countries in having valid and nationally representative overweight or obesity is also a growing concern. In household survey-based statistical evidence for only Bangladesh, the proportion of women with overweight national and divisional levels; there are very limited (≥25·0 kg/m2) has increased from 3 % in 1996 to 24 % in statistics or data available for sub-division or district level. 2014(14). The rate of increase is faster than in India (10·6% Additionally, research conducted to assess the regional in 1999 to 20·2 % in 2016) and Nepal (9·0 % in 2006 to inequalities in health and nutrition has been very limited. – 22·0 % in 2016)(16 19). The most recent public health The issue of geographical differences in undernutrition as concern is childhood overweight or obesity because the well as overnutrition has emerged as a matter of concern prevalence has increased at an alarming rate, particularly considering growing evidence of the strong persistence of in urban areas(20). Thus, identifying the reasons behind existing inequalities(8,34). However, national analyses, the slow progress of undernutrition and the drastic although useful, have little programmatic value for advo- increase of overnutrition prevalence has become a cacy because they fail to highlight the extent of geo- challenge for public health researchers. Studies conducted graphical inequalities that is essential for designing in the last decade have identified maternal education, appropriate interventions and policies on nutrition and socio-economic status, short birth spacing, food insecurity health. Thus, the focus of the present study was to and low birth weight as potential factors associated with investigate the nutritional status of women and children at – undernutrition(21 25). the district level to identify the vulnerable districts and to Over the last decade, Bangladesh has demonstrated understand the full extent of geographical and social significant improvement on each of these fronts; never- inequalities in relation to sociodemographic variables. We theless, progress might not be the same for all regions of also analysed data about maternal demographic factors to the country(26). For instance, urban people are in better understand the social determinants of both under- and condition concerning many sociodemographic aspects overnutrition. The findings from the study will help policy compared with their rural counterparts, where about 75 % makers design appropriate policies and programmes of the population resides(27). Therefore, it is essential to to reduce the burden of under- and overnutrition and to scrutinize the regional variation and identify the regions achieve Sustainable Development Goal 2.2. (districts) with high prevalence where imperative actions are required for quick improvement. Similarly, studies have indicated that the most common factors associated Materials and methods with overnutrition (overweight or obesity) are the imbal- ance between food intake and energy expenditure and Study design and participants low physical activity(28,29). However, food habits and types The data for the present study were extracted from the of physical activity vary across the regions of the country, 2014 Bangladesh Demographic and Health Survey particularly between urban and rural areas. Therefore, it is (BDHS) conducted between July and November 2014. The also necessary