To assess the risk factors for acute malnutrition (weight-for-height
One of every five children aged less than 5 years in low-income, developing countries is malnourished. Globally, undernutrition is associated with more than one-third of all deaths in this age group [
It is well documented that poverty and malnutrition, regardless of location, are highly intertwined. Although risk factors for malnutrition have been identified, individual factors potentially change in specific areas over time and a current characterisation of risk factors provides the basis for preventative intervention programmes.
The study was conducted in the Dhaka Hospital of the International Centre for Diarrhoeal Disease Research (icddr,b) situated in Dhaka, Bangladesh, a metropolitan area (1,500 sq km) with a total population of ~15 million. Each year, the Dhaka Hospital provides care and treatment for over 120,000 patients with diarrhoea, with or without other associated health problems. The hospital also conducts research on enteric and other common infectious diseases as well as undernutrition and provides training on case management of diarrheal diseases, management of malnutrition, and research methodology. Under-five children constitute about 60% of the total patient population and most (~60%) are from poor socioeconomic communities in urban and periurban areas of Dhaka.
A nonmatched case-control study design was used to assess and identify potential risk factors associated with acute malnutrition/wasting among 6–59-month-old children. Children in this age group without any congenital anomaly or other chronic conditions causally associated with malnutrition (e.g., heart disease), who were admitted to the Dhaka Hospital of icddr,b from June to September 2012, were enrolled. Using the contemporary growth standards of the World Health Organization (2006) and ANTHRO software [
One of the investigators and/or a research assistant interviewed the mother/caregiver using a pretested, structured questionnaire. Data recorded from the interviews included age and sex of child, birth order, number of total and under-five siblings, feeding and immunisation history, type of house hold latrine, marital status of mother, monthly family income, and parental age, education, and occupation. Children’s nude weight using a frequently standardised digital scale with 10 g precision (Seca, model 345, Hamburg, Germany) and recumbent length to the nearest mm using a calibrated, locally constructed length board were obtained. Mother’s (if present) weight and height were measured using standard procedures [
Data were entered using SPSS software for Windows (version 11.5) (SPSS Inc., Chicago, IL, USA). For normally distributed continuous variables, means were compared using unpaired
A total of 449 children were enrolled, of whom 178 were cases (wasted children) and 271 were controls. Their overall mean ± SD age was
Characteristics (continuous variables) of the cases (wasted) and controls (nonwasted) children.
Variable | Case |
Control |
|
---|---|---|---|
Child’s age (months) |
|
|
0.004 |
Weight-for-length |
|
|
<0.001 |
Weight-for-age |
|
|
<0.001 |
Length-for-age |
|
|
<0.001 |
BMI-for-age |
|
|
<0.001 |
Total number of children in the family |
|
|
0.270 |
Exclusive/predominant breastfeeding (month) |
|
|
0.042 |
Birth order |
|
|
0.365 |
Mother's age (years) |
|
|
0.737 |
Mother's weight (kg) |
|
|
<0.001 |
Mother's height (meter) |
|
|
<0.001 |
Mother's body mass index (kg/M2) |
|
|
<0.001 |
Mother's education (years) |
|
|
<0.001 |
Father's age (years) |
|
|
0.249 |
Father's education (years) |
|
|
<0.001 |
Total family income per month (takab) |
|
|
<0.001 |
All data are expressed as mean ± SD. aIn relation to the WHO 2006 standard [
Characteristics (attributes) of the cases (wasted) and controls (nonwasted) children.
Variable | Case |
Control |
|
---|---|---|---|
Child’s age > 1 year: |
67 (37.6) | 62 (22.9) | 0.001 |
Girls: |
74 (41.6) | 99 (36.5) | 0.283 |
Did not receive BCG: |
5 (2.8) | 1 (0.4) | 0.038 |
Did not receive pentavalent/polio vaccine |
16 (9.0) | 23 (8.5) | 0.984 |
Did not receive measles vaccine (among >9 months old; |
31 (28.4) | 26 (18.3) | 0.041 |
Predominant breastfeeding stopped before 4 months: |
76 (42.7) | 85 (31.4) | 0.010 |
Teenaged mother (<20 years): |
23 (13.4) | 21 (7.9) | 0.045 |
Shorter mother (height < 1.5 meters): |
86 (54.4) | 110 (44.5) | 0.033 |
Undernourished mother (BMI < 18.5): |
52 (32.5) | 37 (14.9) | <0.001 |
Illiterate or less educated (<5 years’ schooling) mother: |
101 (56.7) | 88 (32.5) | <0.001 |
Mother working outside of the home: |
15 (8.4) | 12 (4.4) | 0.063 |
Divorced/widowed mother: |
16 (9.0) | 3 (1.1) | <0.001 |
Younger father (age < 25 years): |
44 (25.4) | 37 (14.3) | 0.003 |
Illiterate or less educated (<5 years’ schooling) father: |
92 (52.6) | 72 (27.0) | <0.001 |
Father with low-paid job: |
149 (83.7) | 139 (51.3) | <0.001 |
Monthly income < 10000 takaa: |
121 (70.3) | 136 (51.5) | <0.001 |
Using unsanitary latrine: |
10 (5.6) | 3 (1.1) | 0.006 |
Child worn any thread or amulet: |
94 (53.1) | 157 (57.9) | 0.331 |
Child worn kajalb at the side of fore head: |
139 (78.1) | 219 (80.8) | 0.549 |
All data are expressed as number (%). aTaka (Bangladeshi currency: 1 UD$ = 80 taka, average rate during the study period); ba black mark/line used over eyelash by females and side of forehead in some children in Indo-Pak subcontinent.
Factors associated with acute malnutrition (wasting): results of logistic regression model.
Attribute | Adjusted odds ratio | 95% CI of adjusted OR |
|
|
---|---|---|---|---|
Lower | Upper | |||
Child’s age > 1 year | 3.144 | 1.431 | 6.904 | 0.004 |
Did not receive measles vaccine (among >9 months old; |
2.492 | 0.973 | 6.378 | 0.057 |
Predominant breastfeeding stopped before 4 months | 2.669 | 1.229 | 5.796 | 0.013 |
Teenaged mother (<20 years) | 1.758 | 0.451 | 6.847 | 0.416 |
Shorter mother (height < 1.5 meters) | 1.399 | 0.686 | 2.851 | 0.355 |
Undernourished mother (BMI < 18.5) | 2.803 | 1.203 | 6.532 | 0.017 |
Illiterate or less educated (<5 years’ schooling) mother | 1.676 | 0.754 | 3.728 | 0.205 |
Younger father (age < 25 years) | 1.614 | 0.682 | 3.815 | 0.276 |
Illiterate or less educated (<5 years’ schooling) father | 1.186 | 0.525 | 2.682 | 0.681 |
Father with low-paid job | 5.778 | 2.537 | 13.157 | <0.001 |
Monthly income < 10000 taka a | 2.871 | 1.310 | 6.291 | 0.008 |
Using unsanitary latrine | 1.505 | 0.078 | 29.173 | 0.787 |
Constant | 0.016 | — | — | 0.001 |
aTaka (Bangladeshi currency: 1 UD$ = 80 taka, average rate during the study period).
The aim of this study was to identify risk factors associated with acute malnutrition (WHZ < −2, which includes both moderate and severe wasting) in our population of 6–59-month-old children. Our study shows that the major associated/risk factors for acute malnutrition among these children were older age of the child, undernourished mother, jobless father or father with a low-paying job, low total family income, and poorer breastfeeding practices. Some of these factors may operate in synergy to increase the risk of acute malnutrition.
Older age as a risk/associated factor for acute malnutrition of children in our study might reflect a selection bias. However, Jeyaseelan and Lakshman from Tamil Nadu, India [
Similar to other studies from Bangladesh [
The fathers of most (84%) of the wasted children in our study were rickshaw pullers or day laborers. Likewise, a study from South India [
Our finding of improper/inadequate breastfeeding as an associated factor with acute malnutrition is in accordance with the findings of several other studies [
One of the possible limitations of the present study is that the same personnel who obtained the anthropometric measurements of the children and mothers also conducted the interviews, so interviewer biases could be there. However, most of the variables identified as risk/associated factors for acute malnutrition in our study were objective in type. The other limitation was the cross-sectional nature of the present study, which did not allow us to state the identified associated factors as definite causally related risk factors.
The children suffering from acute malnutrition often need supplementary food. In this regard it is worthwhile to mention that icddr,b has developed ready-to-use foods using locally available food ingredients. These foods can be used to prevent and to treat moderate wasting in children living in food-insecure communities. Moreover, the associated factors identified for acute malnutrition in this study can be incorporated into the design and targeting of preventive interventions. Factors such as breastfeeding practices are potentially modifiable. Interventions that motivate behaviours more consistent with recommended infant and young child feeding practices would be expected to have a positive impact. Certain factors and possible causes of acute malnutrition are complex and involve societal and broad-based preventive programs.
None of the authors/investigators has any financial interests that might affect the results of this study.
Each author has taken part in conception and design, analysis and interpretation of data, and drafting and/or revising the paper.
This study was supported by icddr,b. This research/study was funded by core donors which provide unrestricted support to icddr,b for its operations and research. Current donors providing unrestricted support include Australian Agency for International Development (AusAID), Government of the People’s Republic of Bangladesh, Canadian International Development Agency (CIDA), Swedish International Development Cooperation Agency (Sida), and the Department for International Development, UK (DFID). The authors gratefully acknowledge these donors for their support and commitment to icddr,b’s research efforts. They sincerely appreciate Professor G. J. Fuchs, Department of Pediatric Gastroenterology and Nutrition, Arkansas Children’s Hospital, USA, for his excellent review and input in this study. The study and its reporting are approved by the institutional review board of icddr,b without any ethical concern.