The ‘Household’ Double Burden of Malnutrition

1. Katherine Bates (LSE) S.V. Subramanian (HSPH) The ‘Household’ Double Burden of Malnutrition

2. 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) Introduction to the Double Burden of Malnutrition

3. 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 The ‘household’ level DBM

4. Stunted Children and Mothers BMI across Countries

5. Albania Swaziland TimorLeste Honduras Stunted Children and Mothers BMI by GNI

6. Jordan Bolivia Sao Tome e Principe Albania Mali Guyana Timor Leste Stunted Children and Mothers BMI by % Urban Lesotho

7. What determines the HHDBM among stunted children? • Prenatal hypotheses: • Foetal origins of adult disease (FOAD) • Postnatal hypotheses: • Intrahousehold Behaviours • Dietary Quality Aim of study

8. 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 Methodology

9. Results

10. 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 Discussion

11. A further caveat… The nutritional profile of stunted children varies, Stunted Stunted & wasted Stunted overweight Does this, and in particular, the individual level DBM affect our understanding of the HHDBM?

12. Child stunted profiles for under-fives with overweight mothers by country (%)

13. GNI per capita and % Stunted Children with Overweight Mothers Albania Maldives

14. Albania

15. Results - Multinomial • p<0.05, ** p<0.01, *** p<0.001 • N 12329

16. For the stunted-overweight: • 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 Discussion • 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

17. Disaggregation of ‘stunted child, overweight mother’ pairs • Understand biological and behavioural determinants within this group Future

18. Funded by the Agnes Metcalfe Studentship for Women (LSE)