Chowdhury et al. Globalization and Health (2018) 14:54 https://doi.org/10.1186/s12992-018-0372-7 RESEARCH Open Access Socio-economic risk factors for early childhood underweight in Bangladesh Tuhinur Rahman Chowdhury1*, Sayan Chakrabarty2,3, Muntaha Rakib1, Sue Saltmarsh3 and Kendrick A. Davis4 Abstract Background: Underweight is a major cause of global disease burden. It is associated with child mortality and morbidity, and its adverse impact on human performance and child survival is well recognized. Underweight is a major public health problem in Bangladesh, which is amongst the highest underweight prevalent countries in the world. The objectives of our study were to determine the national and regional prevalence rates of underweight and severe underweight in Bangladesh, and to investigate the association of socioeconomic and demographic factors with child underweight and severely underweight among children under the age of five living in Bangladesh. Methods: We performed a cross sectional study using Multiple Indicators Cluster Survey 2012–13, Bangladesh data on 17,133 children under 5 years of age. Weight-for-age Z scores based upon World Health Organization (WHO) guidelines were used to define child underweight and severe underweight. The association of underweight and severe underweight with household socioeconomic factors and demographic characteristics was investigated using binary logistic regression model. Results: An estimated 31.67% children were underweight and 8.81% children were severely underweight. Children of mothers with incomplete secondary education [Odds Ratio (OR) = 0.84, 95% CI: 0.75, 0.94] and mothers with completed secondary education [Odds Ratio (OR) = 0.77, 95% CI: 0.64, 0.93] were less likely to be underweight than children of uneducated mothers who had no formal schooling. A similar association exists for father’s education, children from households in the highest wealth index quintile had lower likelihood of underweight [Odds Ratio (OR) = 0.44, 95% CI: 0.37, 0.53] than children from households in the lowest quintile. Consumption of non-iodized salt had higher risk of severe underweight for children aged between 24 and 35 months [Odds Ratio (OR) = 2.32, 95% CI: 1.80, 3.00]. Other risk factors of child severe underweight included living in Sylhet division and increases in the number of children under the age of five in a household. Conclusion: Underweight was associated with lower parental education, household position in lower wealth index, living in Sylhet division and consumption of non-iodized salt. Strategies are discussed considering the relative importance of risk factors for child underweight. Keywords: Determinants, Underweight, Bangladesh, Child, Early childhood Background children who are mild to moderately malnourished com- Developing countries have the greatest prevalence of pared with well-nourished children [5, 6]. The adverse early childhood malnutrition despite recent rapid eco- impacts of malnutrition are not limited to school attend- nomic development [1–3]. Malnutrition is the prime ance rates and academic accomplishments, but also culprit for early childhood death, causing the deaths of linked to decreases in the development of social skills 13 million infants and children under the age of five among children [7, 8]. Malnutrition is associated with every year [4]. There is a higher risk of dying among poorer academic performance in school-aged children [9] and lower survival capacity for a child in its adult- * Correspondence: [email protected] hood [10]. 1Department of Economics, Shahjalal University of Science & Technology, Sylhet Kumargaon, Sylhet 3114, Bangladesh Full list of author information is available at the end of the article © The Author(s). 2018 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. Chowdhury et al. Globalization and Health (2018) 14:54 Page 2 of 12 Malnutrition status is investigated using three an- education. Mohsena et al. [24] explored the Bangladesh thropometric parameters: height for age, weight for Demographic and Health Survey (2004) Data and found height and weight for age [11]. Height for age is used that higher levels of maternal education are associated to identify stunting1 which represents linear growth with lower risk of underweight. In Bangladesh, paternal failure for a child [12]. Weight for height is used to education was also found to be an independent deter- identify wasting2 which indicates an unusually body tissue minant of child underweight by few studies [27, 33]. Ac- and fat mass for a child relative to its height or length cording to Das et al. [33], children of illiterate fathers [13]. Weight for age is the WHO-recommended indicator had a 30% higher likelihood of being underweight to determine whether the child is underweight3 or not than the children of fathers who had completed pri- [11]. As underweight is a composite indicator that encom- mary school. Another study that finds a positive asso- passes both stunting and wasting [14] implying that stunt- ciation between paternal education and risk of child ing, wasting or both can be reflected by underweight [15], underweight [26]. our primary interest is to use weight for age indicator to Socioeconomic status like poverty is also a signifi- measure early childhood underweight. cant predictor of child underweight. Children coming Underweight has become a major public health from poor families are more likely to be underweight problem particularly in developing nations, and its compared with children coming from wealthier fam- destructive impact on human performance and child ilies [4]. Despite the fact that Bangladesh has man- survival has been well recognized [16]. It is a prime aged to achieve an enormous economic growth in the concern as underweight is the leading cause of global last 20 years along with massive improvements in disease burden [17]. Underweight is associated with educational achievement, still a large proportion of its increased risk of contagious disease such as diarrhea population, nearly 43.3%, are living under the poverty and pneumonia [18]. The World Health Organization line of 1.25 dollar per day [28]. Having such a large (WHO)citesunderweightas the single largest risk proportion of the population living in poverty, hence factor in developing countries to the burden of dis- unable to afford nutritious food or access improved ease, [19] as an estimated 52.5% of all deaths among health care facilities, makes the task of reducing the coun- young children are attributable to underweight [18]. try’s prevalence of underweight children extremely difficult. In the countries where child mortality is high, under- Indeed, a number of studies conducted in Bangladesh sug- weight is accountable for 15% of the total disability gested household socioeconomic status as a significant de- adjusted life years losses [17]. Underweight children terminant of child underweight, reporting that children are 8.4 times more likely to die and children who are from relatively higher socioeconomic condition had lower suffering from moderate and mildly underweight are likelihood of being underweight [28, 33]. A study in 4.6 times and 2.5 times respectively more likely to die Bangladesh carried out by Alom et al. [29]reportedthat before the age of five compared to children who are children who came from the richest wealth index had 44% well-nourished [5]. lower odds of being underweight compared with children In 2011, 101 million children globally were estimated as from the poorest wealth index. underweight indicating the prevalence rate of underweight Among the socioeconomic determinants, most of the as 16% [20]. The situation is worse in Bangladesh, where studies conducted in Bangladesh confirmed that mothers’ underweight prevalence rate was reported to be 41% [21]. literacy status, choice of latrine and poor household in- There are many socioeconomic and biological factors that come are the associated risk factors for underweight are associated with child underweight. Biological factors among children under five [25, 27, 29, 30]. Other risk fac- include lower birth weight [22], having an underweight tors estimated as significantly associated with the risk of mother or father, and having a mother or father of short child underweight are improper feeding practices, mater- stature. Among the socioeconomic factors, children with nal antenatal and postnatal care, diarrhea of children mothers who don’t have any formal education are at within last 2 weeks [32]; living in rural area [30]; mothers greater risk of being underweight [23]. having less exposure to media, children of mothers work- Even though Bangladesh has one of the highest preva- ing outside home [31]; unimproved toilet facilities, and liv- lence of underweight in the world, few studies have inginSylhetdivision[33]. The risk of being underweight identified the socioeconomic factors responsible for among under-five children was observed to increase with child underweight [24–30]. Most