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CHAPTER 1 INTRODUCTION
1.4 RESEARCH QUESTION
1.5 AIM AND OBJECTIVES
CHAPTER 2 LITERATURE REVIEW
2.2 REVIEW OF THE LITERATURE METHODOLOGY
2.3 REVIEW OF THE LITERATURE
2.3.1 Research Question
2.3.2 Rationale of the Study
2.4 MALNUTRITION AND CHILD MALNUTRITION
2.5 MEASUREMENT OF CHILD MALNUTRITION
2.6 PREVALENCE OF CHILD MALNUTRITION
2.7 DETERMINANTS OF CHILD MALNUTRITION
2.7.1 Demographic Factors
2.7.2 Low Birth Weight
2.7.3 Lack of Postnatal Care
2.7.4 Socio-economic Factors
2.7.8 Food Insecurity
2.7.9 Environmental Factors
2.7.10 Poor Housing
2.7.11 Parental Smoking
2.7.12 Dietary Factors
2.7.13 Poor Practice of Exclusive Breastfeeding
2.7.14 Poor Feeding Practices
2.7.15 Micronutrient Deficiency
2.7.16 Immunisation Factors
2.7.17 Presence of Chronic Disease
2.8 IMPACT OF CHILD MALNUTRITION
2.8.1 Physical Consequences of Child Malnutrition
2.8.2 Economic Implications of Child Malnutrition
2.9 PROMOTIONAL STRATEGY
2.9.1 Public health nutrition program under MOHFW
2.9.2 The Bangladesh Integrated Nutrition Programme (BINP)
2.10 PREVENTATIVE STRATEGY
2.10.1 Vitamin-A Supplementation Programme
2.11 MANAGEMENT STRATEGY
CHAPTER 3 RESEARCH METHODOLOGY
3.2 FRAMING RESEARCH (REVIEW) QUESTION
3.3 RESEARCH DESIGN/APPROACH
3.3.1 Inclusion and Exclusion Criteria
3.4 INCLUSION AND EXCLUSION CRITERIA
3.5 SEARCH STRATEGY
3.5.1 Boolean Operators
3.6 SCREENING STRATEGY
3.6.1 Title and Abstract Screening
3.6.2 Full Manuscript Screening
3.7 RESULT FROM SEARCH
3.8 DATA EXTRACTION
3.9 DATA SYSTHESIS
3.10 ETHICAL APPROVAL
3.12 QUALITY APPRAISAL
CHAPTER 4 RESULTS
4.1 RESULT OF THE SEARCH
4.2 FINDINGS OF THE STUDY
4.3 SUMMARY OF THE SELECTED EIGHT STUDIES
4.4 SYNTHESIS OF THE SELECTED STUDIES
4.5 QUALITY ASSESSMENT
CHAPTER 5 DISCUSSION
5.1 DISCUSSION OF THE REVIEW STUDY
5.2 STRENGTHS OF THE STUDY
5.3 LIMITATIONS OF THE STUDY
5.3.2 Availability of Data
5.3.4 Validation of the Used Data
5.3.5 Data Analysis
5.3.6 Research Question
5.3.7 Study Design
5.3.8 Study Area
5.4 IMPLICATIONS OF THE STUDY FOR POLICY AND PRACTICE .
CHAPTER 6 CONCLUSION
6.2 COMMENDATION FOR FUTURE RESEARCH
6.3 REFLECTIVE THOUGHTS ABOUT THE STUDY
6.4 FINAL THOUGHTS
ANNEX 1: DATA EXTRACTION TEMPLATE
ANNEX 2: QUALITY ASSESSMENT TOOL
Table 1 Classification of Malnutrition Based on Percentage of Loss of Body Weight
Table 2 Wellcome Classification of Severe Malnutrition in Children,
Table 3 Nutritional Status of Children in Bangladesh in 2011
Table 4 Sample Distribution and Prevalence of Stunting among Children age 0-59 Months by Household Wealth Status and Other Selected Characteristics, Bangladesh 2004
Table 5 Percentage of Under-Five Children in Different Categories of Malnutrition According to Significant Risk Factors
Table 6 List of Inclusion and Exclusion Criteria
Table 7 Summary of the Search
Table 8 Findings of the Study
Table 9 Summary of Quality Appraisal of Eight Studies
Table 10 Summary of the Quality Grade of Eight Primary Studies
Figure 1 Conceptual framework for malnutrition
Figure 2 Nutritional Status of Children by age
Figure 3 Classification of child malnutrition based on Anthropometric Measurement
Figure 4 Trend of protein energy malnutrition among under five years children in Bangladesh
Figure 5 Trend of nutritional status by region (October- December 2012)
Figure 6 Prevalence of underweight, stunting and wasting among under - five children in rural, urban and slum areas in Bangladesh in 2013
Figure 7 Trends in nutritional status of children age group below 5 years in 2004, 2007, 2011
Figure 8 Proportion of study children improved by WAM above 75% of median of the NCHS standard from baseline up to end of 6 month observation
Figure 9 Human capital diagram through improvement of child malnutrition
Figure 10 Flow chart of the relevant study selection process through screening strategy 36 Figure 11 Flow diagram of the articles selection procedure
Figure 12 Pyramid Presentation of the Screening Process of relevant Article
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I am grateful to the Merciful Almighty whose mercy enables me to complete my research work successfully. I would also like to express my cordial gratitude to my beloved parents for their continuous inspirations and support.
I would like to give my heartiest thanks to my respectable supervisor Professor Gurch Randhawa, Professor of Diversity in Public Health and Director of Institute for Health Research at University of Bedfordshire, for his valuable suggestions, guidance, and constructive advice during meeting to conduct this review study.
I am thankful to my personal tutor Dr Krishna Regmi, Principal Lecturer in Public Health and Public Health Portfolio Lead, for his technical guidance, inspiration, and continuous support from the beginning of my study period. I am also gratified to Dr Shuy Puthussery, Unit Co-Ordinator, for her guidance and support. Moreover, I want to give special thanks to my department teacher Dr Anthony Farrant, Dr Chris Papadopoulos, Dr Ruth Gilbert, Dr Nasreen Ali, Dr Hala Evans, and Dr Dong Pang giving me their special academic support, encouragement, and recommendations during the academic period.
I am also grateful to our department and IT staff, University of Bedfordshire. They cordially facilitated me as much as possible in every step to conduct this review study. In addition, I am pleased to all of my friends and colleagues who recommended and helped me during the study time in the University Library.
July 2015 KAMALESH CHANDRA DEY
Child malnutrition is the supreme concern of public health department in Bangladesh. Every two pre-school children are malnourished in Bangladesh. However, Bangladesh has achieved Millennium Development Goals (MDGs) 3 in the past years and MDG-4 is on track. Consequently, the rate of child malnutrition has reduced somewhat due to the improvement of both health care practice and policy system in Bangladesh in the period between in 1999 (56%) and in 2014 (43~36.8%).
The aim of this review study is to find out the prevalence and determinants of child malnutrition in Bangladesh. In addition, the review study will also help future researcher and health policy maker to modify existing nutrition policy through the various nutritional intervention programs in the community and school level to improve the nutritional status of children in Bangladesh.
The review study design was conducted through the systematic review protocol. The author searched relevant primary studies in the numerous databases using Boolean operator in the period of February 2015 to July 2015. Total eight primary studies were included in this review as they met all the inclusion criteria. In addition, data was collected from the selected eight primary studies and extracted onto the standard data extraction template. Afterwards, the EPHPP tool was used to appraise an individual studies to measure their quality grade. Finally, narrative synthesis was used to analyse data, while meta-analysis was not suitable.
The review study included total eight primary studies and majority of the articles were cross- sectional studies and conducted in both school and community level. Where, six studies described both prevalence and determinants of child malnutrition in Bangladesh, while rest two studies simply identified the determinants of child malnutrition. In addition, two prevalence studies reported that about 43% children were malnourished, while other prevalence studies reported that maximum 25% and 10% children were stunted and wasted respectively. Moreover, four studies identified that poverty, parent’s occupation, household food in-security and low household income was closely associated with child malnutrition. Further three studies stated that duration of breast feeding, poor food consumption and complementary feeding were linked with child malnutrition. Besides, five studies reported that presence of infectious diseases, childcare, and access of health care were closely linked with child malnutrition. Additionally, four studies indicated that BMI and education level of mothers, age of children, birth order, and place of delivery were significantly associated with child malnutrition. Furthermore, one study identified that gender inequalities and parental smoking were positively associated with child malnutrition in Bangladesh.
Conclusion and Implication
The review study concluded that about 43% malnourished, 39.5% stunted, and 14% wasting children living in Bangladesh. In addition, the review study also summarised that poverty, lack of exclusive breastfeeding, frequency of complementary feeding, food in-security, access to health care, parental education, occupation of parents, and presence of various infectious diseases were significantly associated with child malnutrition and known as determinants of child malnutrition in Bangladesh. Moreover, the findings will also contribute in further research and help to policy maker to amend new nutrition policy through cost- effective nutritional intervention program immediately to improve the nutritional status of children in Bangladesh.
Child malnutrition or under-nutrition, protein energy malnutrition or stunting, or wasting or underweight, obesity or overweight, prevalence or rate or case or incident, determinants or risk factors, Bangladesh;
Child malnutrition is a major public health concern in Bangladesh. It is the root causes of morbidity and mortality amongst pre-school and school going children in Bangladesh. United Nations Development Programme (UNDP) reported that child malnutrition is the most significant drawback to achieve Millennium Development Goals (MDGs) four in Bangladesh (UNDP, 2013). Consequently, child malnutrition is known as national burden as majority of the pre-school and school going children are suffering nutritional problem for instances stunting, wasting, kwashiorkor and marasmus kwashiorkor. In addition, child malnutrition not only in Bangladesh but also in other developing and under-developing countries in the world for instances India, Pakistan, Nepal, and Afghanistan (Jesmin et al., 2011). Save the Children (2012) reported that one in every four children is stunted due to only lack of nutrition and more than 2.6 million child deaths every year in the world. Besides, the child mortality rate is about 60% due to only nutrition related problem in Bangladesh (Faruque et al., 2008).
Moreover, Protein energy malnutrition is also prime public health concern in Bangladesh. It is act as growth hindrance factor and directly retards the physical growth and development of children. Rahman et al. (2008) reported that child malnutrition is the crucial factors of child mortality and morbidity in Bangladesh. In addition, Ali et al. (2013) stated that there are many risk factors associated with child malnutrition including poverty, household food insecurity, or food shortage and micronutrient deficiencies in Bangladesh. Furthermore, Jesmin et al. (2011) indicated that poverty, lack of childcare, lack of exclusive breastfeeding and improper complementary feeding are the key causes of child malnutrition, while Rahman et al. (2008) indicated that living in poor housing, presence of numerous communicable and non-communicable diseases and micronutrient deficiency are the common factors of child malnutrition in Bangladesh. In rural part of Bangladesh, many children are still under micronutrient deficiency including vitamin-A deficiency (VAD), iron deficiency anaemia (IDA), iodine deficiency disorders (IDD) and zinc deficiency (FAO, 2010). In addition, Khor (2003) reported that about 40% to 50% pre-school and primary school going children are suffering iron deficiency anaemia (IDA) in Bangladesh.
Child malnutrition is still high prevalent in Bangladesh rather than any other countries in the world. Food and Agricultural Organisation (FAO) (2010) reported that about more that, 54% (around 9.5 million) pre-school going children were stunted and 56% were underweight, and higher that 17% children were wasted in Bangladesh. Rahman and Chowdhury (2007) also stated that about 44% children were stunted, while 18% children were severely stunted. Moreover, UNICEF (2009) reported that about 41% children below five years were underweight and 43.2% of children were severely stunted. Additionally, Mostafa (2011) discovered that more than two-fifths children stunted, where about 26.3% were moderately stunted and around 15.1% were severely stunted.
Likewise, UNICEF, WHO, and the World Bank report (2014) stated that about 15.7% children were wasted, 1.9% overweight, and 41.4% stunted 36.8% underweight. However, Jesmin et al. (2011) reported that the rate of child malnutrition has reduced slightly in the past couple of years due to the particular improvements of health care system in the period between 2004 and 2007. Consequently, Bangladesh already has achieved MDG-3, while MDG-4 on tack. To achieve MDG-4, child malnutrition rate need to be reduced by 34% within 2015 (Jesmin et al., 2011). However, Rahman, Chowdhury, and Hossain (2009) found that wasting was high prevalent among children in the period between November 1999 and March 2000, what was higher rather than India. Dutta et al. (2009) reported that the acute rate of child malnutrition was only 10% in India, while child malnutrition was significantly higher in some parts of India including Garhwal Himalayas. In addition, one in every third children was suffering nutritional problem (Dutta et al., 2009).
Moreover, Alom, Quddus, and Islam (2012) purported that about 16% and 3% children were severely stunted and wasted respectively, while about 11% children were severely underweight. In addition, Quddus, and Islam (2012) identified numerous risk factors including child’s age, education of parents, breast-feeding practice, place of birth and quality of housing what were significantly associated with child malnutrition in Bangladesh. Bangladesh, as a developing country these factors are still available to influence child malnutrition. Consequently, more than 50% children are living with malnutrition in Bangladesh and globally, about one million children die and 20 million children under five living with severe acute malnutrition every year (Ahmed et al., 2014). Moreover, Ahmed et al. (2014) recommended that nutritional problem could prevent to build malnutrition free world through the various cost effective preventive measures including nutrition education program, opening community clinic, and nutritional campaign through mass media, and modify existing nutrition policy.
Child malnutrition is the national burden in Bangladesh. At present, obesity, and overweight is the main concern in developed countries, while child malnutrition is still high prevalent in Bangladesh as well as other developing and underdeveloped countries (FAO, 2010). In addition, more than half of the children are living with nutritional problem in Bangladesh (Ahmed et al., 2014). According to global report, about 3.5 million deaths and roughly 35% children below five years are suffering several nutritional disorders (Ahmed et al., 2012), while the 70% undernourished children are living in Asia and rest of the malnourished children are living various parts of the world (Khor, 2003). Therefore, child malnutrition rate is higher in Bangladesh as well as in various Asian countries (including India, Pakistan, and Nepal) rather than other parts of the world. Khor (2003) also reported that 16% children were malnourished in china and one in every two children stunted in Bangladesh.
In addition, Rahman et al. (2012) reported that child malnutrition is the main cause of child morbidity and mortality in Bangladesh. In 2005, almost 50% children were underweight and almost two thirds of children deaths occurred due to only numerous nutritional problem (Rahman et al., 2012). Moreover, Ahmed et al. (2012) also found that more than 0.5 million children living with severe acute malnutrition (SAM) in Bangladesh. BDHS (2011) reported that child malnutrition are more likely high prevalent in rural areas rather than in urban areas in Bangladesh. In rural areas, about 43% children were stunted, while 36% children were stunted living in urban areas (BDHS, 2011).
Therefore, immediate preventive measures are crucial to tackle this current national burden in Bangladesh. However, limited research conducted only on child malnutrition to investigate the fact of this national burden. Hence, this is high time to resolve this crucial problem to find out the associated factors of child malnutrition, gaps of the nutrition policy and research. This nutritional problem is also need to prevent through effective preventive measures soon. The current review study will disclose the current nutritional situation of children and identify the various risk factors of child malnutrition in Bangladesh. The review study will also find out the gaps of existing nutrition policy and main hindrance of the interventional program. Moreover, the review study will also reveal the nutritional status of children in different parts including rural, urban, slum, hilly and riverside of Bangladesh. Furthermore, the review study will investigate hidden facts of child malnutrition and support further research. The review study also help to nutrition policy maker to identify of the associated factors of child malnutrition and highlight of the gaps of the exist policy. The review study will help Bangladesh health department and policy maker to strengthen their mode of action against child malnutrition and to modify existing nutrition policy through worthwhile nutrition intervention programs. Therefore, required immediate action to address the national burden and improve the nutritional status of children in Bangladesh achieving MDG-4.
“What are the prevalence and determinants of child malnutrition in Bangladesh?”
The review study will explore the prevalence rate and determinants of child malnutrition in Bangladesh. Afterward, the review study will conduct to achieve the following objectives:
- To review the relevant primary studies to find out the prevalence rate of child malnutrition (including underweight, stunting and wasting) in various parts of Bangladesh;
- To review the important literature to compare and nutritional status among children living in urban and rural areas in Bangladesh;
- To review the relevant literature to determine the risk factors associated with child malnutrition in Bangladesh;
- To review appropriate literature to explore the association between child malnutrition and risk factors including poverty, lack of childcare or exclusive breast feeding or consumption of food or complementary feeding practice and parental education;
- To review relevant literature to establish the relation between child malnutrition and various determinants including occupation level of parents, food insecurity, presence of infectious disease, various demographic factors;
- To review literature to identify vulnerable age group among children of malnutrition in various parts of Bangladesh;
- To review relevant studies and recommend some interventional strategies to the future researcher, health policy maker and public health department to notify the existing gaps and help to amend new nutrition policy through cost effective intervention strategies to improve the nutritional status in Bangladesh.
Literature review is a crucial step of educational research especially in secondary research, what can help to know the authors and readers regarding the previous investigation on same area of research. Bruce (1994) stated that literature review is the key component of academic research what disseminates initially the actual understanding, context, and rationalisation of the research through separate section between the introduction and methodology part of the entire research. In addition, Randolph (2009) reported that literature review could establish the researcher’s knowledge on specific field including terminology, key concepts, variables, its methodology, and work history.
Moreover, Hart (1998, p.13) defined the literature review the following ways: “The selection of available documents (both published and unpublished) on the topic including information, ideas, data and evidence written from a particular standpoint to fulfil certain aims or express, certain views on the nature of the topic and how it is to be investigated, and the effective evaluation of these documents in relation to the research being proposed”.
In addition, literature review is quite important to fulfil some of particular purposes including notifying significant variables related to topic, categorising relation between practice and thoughts, and constructing framework of the topic or any relevant problem (Harts, 1998). There are some significant studies have been conducted regarding child malnutrition in Bangladesh to investigate the reasons behind it and also find out the key risk factors of child malnutrition. This chapter will reveal the prevalence of child malnutrition in Bangladesh and highlight all the associated factors (known as determinants) of child malnutrition. This review study will also help to the readers providing clear understanding and highlighting the key factors of child malnutrition what will be milestone of this review study. Finally, the study will also relate between the outcomes of this review study and the existing research knowledge on same area.
Searching literature was carried out in the University of Bedfordshire library through online and offline resources, where online databases including Discover, PubMed Central, CINAHL Plus with Full Text and Cochrane through Wiley Library, Science Direct, EBSCOHOST, and Global Health database. In addition, relevant literatures were searched through Discover (database of the University of Bedfordshire). Moreover, Google and Google scholar were also used to find out full text relevant articles, various newspaper articles, health policies, and publications of the Government, national, and International Organisations (NGO’s). Finally, reference list extracted by Refworks.
The following key words were used during the searching relevant literature from the online databases:
Child Malnutrition, Under Nutrition, Nutritional Status, Overweight, Underweight, Stunting, Obesity, Protein Energy Malnutrition, Determinants, Risk Factors, Prevalence, Incidence, Rate, Case and Bangladesh; However, relevant articles were initially accepted based on inclusion criteria including published only between 1995 and 2015, written in English, and study conducted among children in Bangladesh. While, initial selected articles were again excluded for the systematic review study based on exclusion criteria. The articles were systematically reviewed and narrative synthesis was used to analyse extracted data collected from the selected primary studies.
“What is the prevalence and determinants of child malnutrition in Bangladesh?”
Child malnutrition is the most significant public health concern in Bangladesh. High prevalent of child malnutrition is still available in Bangladesh rather than any other countries in the world. As a developing country, majority of the children are living under malnutrition and numerous factors including poverty, education, food in-security, lack of complementary feeding, and lack of exclusive breast-feeding are significantly associated with child malnutrition (Jesmin et al., 2011). However, the nutritional status among children below five years has improved somewhat compare than 2004. According to BDHS (2011), the rate of stunting dropped from 51% in 2004 to 41% in 2011 and the rate underweight reduced from 43% in 2004 to 36 % in 2011. Likewise, achieving the MDG 4 the malnutrition rate needs to reduce significant level (34% within 2015). Consequently, urgent action needs to take tackling this nutritional problem. However, only few studies conducted and there was no significant evidence to minimise the nutritional problem. Therefore, this is the right time to conduct the review study to investigate the gaps of current nutrition policy and practice, and identify the associated factors of child malnutrition. The review study will figure out the current nutritional situation of children in Bangladesh and will determine the significant factors of child malnutrition. The review study will also help further research and support policy maker to identify their existing gaps and amend new policy through effective intervention program to meet MDG-4.
Malnutrition refers to the severe condition caused by consumption of inadequate food containing poor nutrients (NHS, 2014). According to World Food Program (WFP) (2014), malnutrition is just around the corner of any children, when she or he is not eating adequate food or not getting the sufficient nutrition from food. Ultimately, child malnutrition retards physical and mental growth in their childhood (WFP, 2014). Moreover, Rabbi and Karmaker (2014) defined that malnutrition is such a condition commenced through the lack of balanced diet consumption that contain low nutrient or disproportion of various nutrients. Besides, Malnutrition is the complex term of both under nutrition and over nutrition. Under nutrition includes underweight, stunted, wasting, protein energy malnutrition (Kwashiorkor, marasmus, and marasmus kwashiorkor), and micronutrients deficiency (VADD, IDD, IDA) (Ahmed et al., 2012). Moreover, Katsilambros et al. (2011) stated that malnutrition is the unusual condition and caused by bad or faulty nutrition known as under-nutrition.
World Health Organisation (WHO) (2015) defined that “malnutrition is the cellular disproportion between supply of nutrients and energy and the body’s demand for them to ensure growth, maintenance and specific function and greatest risk factors for illness and death worldwide.” Moreover, Malnutrition is general term of physical condition, which denotes the lack of nourishment or inadequate intake of food, and ultimately loss of body weight. Besides, Best (2008) defined that malnutrition might normally appeared after consumption of insufficient accessibility of nutrient due to poor consumption of food in developing countries, while in developed countries, malnutrition is the cumulative results of various diseases. UNICEF (2009) reported that malnutrition is a comprehensive word and usually used as substitute word ‘under-nutrition’ but technically, it means over-nutrition. Furthermore, Ge and Chang, (2001) stated that deficiency diseases due to insufficient and lack of particular nutrients including vitamins and minerals.
The following UNICEF framework (Figure 1) disclosed the causes of malnutrition and the framework related various factors of malnutrition including multi-sectorial factors, food and nutrients, and health and caring practice. In addition, according to UNICEF framework, malnutrition also classified as immediate, underlying and basic, where three levels of malnutrition are related each other’s.
Figure 1: Conceptual Framework for Malnutrition (UNICEF, 1998)
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Particularly, the above framework issued at national, district and local levels to run the cost effective action plan to reduce the nutritional problem nationally (UNICEF, 1998).
Malnutrition can be measured by different ways. Especially, the state of insufficiency or additional of energy, protein, fat, and carbohydrate and other nutrients lead to measure adverse effects on tissue, body function and appearance and clinical outcomes (Katsilambros et al., 2011). In addition, Malnutrition can be classified into various ways including loss of body weight (Table 1) based on the percentage of usual weight and based on severity of malnutrition in children for instance PEM in children based on percentage of expected weight for age and the presence or absence of oedema (Table 2).
Table 1: Classification of Malnutrition Based on Percentage of Loss of Body Weight (Katsilambros et al., 2011)
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Table 2: Wellcome Classification of Severe Malnutrition in Children, Oedema (Katsilambros et al., 2011)
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According to BDHS (2001), three basic indicators including Stunting (Height for age), Wasting (Weight for height) and Underweight (Weight for age) (Table 3), normally used to measure the nutritional status among children based on physical growth. Stunting denotes the linear physical growth and it is the result of collective outcome of various chronic illness or malnutrition. Therefore, stunting is the long-term negative impact of malnutrition (BDHS, 2011).
Table 3: Nutritional Status of Children in Bangladesh in 2011 (BDHS, 2011)
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In addition, wasting denotes too tinny body shape according to the height of particular children known as wasted and it is the result of the recent or acute deficiency of nutrition. However, >-3SD denotes severe stunting and wasting, while severe wasting is extremely associated with childhood mortality (BDHS, 2011).
Figure 2: Nutritional Status of Children by Age (BDHS, 2011)
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“Note: Stunting reveals chronic malnutrition; wasting reveals acute malnutrition; however, underweight reflects chronic or acute malnutrition or a combination of both. Used plotted values were levelled by a five-month moving average”.
Furthermore, BDHS (2011) reported that underweight is the combined indicator of height for age (stunting) and weight for height (Wasting) (Figure 2). In addition, weight for age (underweight) is the common indicator, which is used to measure nutritional status of children in Bangladesh BDHS (2011).
According to WHO (2015), child malnutrition is classified into four ways including underweight, stunting, wasting and overweight based on their anthropometric measurement (Figure 3). However, this measurement only applicable for the children age group above 5 years.
Figure 3: Classification of Child Malnutrition based on Anthropometric Measurement (WHO, 2015)
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Child Malnutrition is the fundamental cause of child mortality and morbidity in the developing and underdeveloped countries in the world. The prevalence of child malnutrition is still higher in Bangladesh comparatively any other countries in the world. Likewise, child malnutrition is also prevalent in India, Pakistan, Nepal, and other South Asian countries. According to FAO (2010), prevalence of child malnutrition was quite higher in Bangladesh, where pre-school children are mostly vulnerable and about 56% children were underweight, more than 17% are wasted and 54% are stunted. In addition, Ahmed et al. (2012) reported that about 3.5 million deaths and approximately 35% children living with numerous nutritional problem globally.
In addition, Rahman et al. (2012) identified that malnutrition is the most significant and primary cause of child morbidity and mortality in Bangladesh. In 2005, majority of the children were underweight and stunted, and approximately two thirds of deaths only due to malnutrition (Rahman et al., 2012). Ahmed et al. (2012) also reported that more than 0.5 million children with severe acute malnutrition (SAM) were living in Bangladesh. BDHS (2011) also reported that total 8,550 children under five years were underweight. According to national nutritional survey 2007, the rate of underweight and stunting was 41% and 43% respectively (Quddus and Bauer, 2013).
Directorate General of Health Services (DGHS) (2014) reported that about 41% children below five years were stunted and 15% children were severely stunted. Moreover, BDHS (2011) categorised child malnutrition into three sub categorise includes height for age known as stunting, weight for height known as wasting, and weight for age known as underweight. Besides, Jesmin et al. (2011) reported that in Bangladesh about 36% children born at low birth weight and about 400,000 children below five years living with severe acute malnutrition where PEM is the most common. However, BDHS (2007) revealed that the prevalence rate of stunting declined considerably from 51% in 2004 to 43% in 2007. While, achieving MDG-4 child malnutrition rate need to reduce by 34% within 2015.
BDHS (2011) reported that maximum 52% children age group between 18 and 23 months stunted, while minimum 17% children age group between 6 and 8 months stunted. BDHS (2011) also reported that child malnutrition is more prevalent in rural areas rather than in urban areas. In rural areas, the rate of stunting was 43%, while in urban areas the rate was 36%. However, the rate of stunting was the lowest (34%) in Khulna and Rajshahi, while the rate of stunting was not stable in other parts of Bangladesh for instance 41% in Chittagong and 49% in Sylhet (BDHS, 2011).
Additionally, BDHS (2011) reported that the average wasted rate was 16% and the highest and lowest rate was 17% and 14% among age group 18-23 months and 9-11 months respectively. While, male children were more likely vulnerable and the average rate of wasting was 16% and 15% between male and female respectively. However, DGHS (2014) reported that the rate of stunting reduced somewhat from 51% in 2004 to 41% in 2011, while the rate of stunting was 43% in 2007 (Figure 4). Moreover, According to Figure 5 and 6, the level of wasting also slightly reduced from 17% in 2007 to 16% in 2011 and the rate of underweight was (36%) in 2011 compare to 41% in 2007 (DGHS, 2014). However, Health, Population, and Nutrition Sector Development Program (HPNSDP) already made a plan to achieve MDG-4 and the prevalence rate will cut down by 2015.
Figure 4: Trend of Protein Energy Malnutrition among Under Five Years Children in Bangladesh (DGHS, 2014)
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Furthermore, according to data, around 56% of children were malnourished, around 54% of pre-school children are stunted, and additional higher than 17% of children are wasted (FAO, 1999). In addition, Khor (2003) stated that about 70% of the world’s undernourished children live in Asia, so prevalence of child malnutrition is the highest in this region.
Figure 5: Trend of Nutritional Status by Region (October- December 2012) (DGHS, 2014)
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In addition, the prevalence of underweight was 49.8% and 64.0% in Khulna and Sylhet division of Bangladesh respectively. Likewise, the highest prevalence of stunting and wasting were about 61.4% and 20.9% respectively. While, the rate of stunting declined progressively over the last 10 years (FAO, 2010). Additionally, Hasan et al. (2013) indicated that the prevalence of child malnutrition is higher in rural areas than that of urban areas in Bangladesh. Moreover, in rural and urban area severe underweight children were about 62.1% and 37.9% respectively (Hasan et al., 2013). Besides, in rural and urban areas moderate stunted children were about 58.6% and 41.4% respectively (Hasan et al., 2013). Furthermore, in rural and urban areas wasted children were 62.5% and 37.5% respectively. While, data revealed that girls were more malnourished compare than boys (Hasan et al., 2013).
Figure 6: Prevalence of underweight, stunting and wasting among under -five children in rural, urban and slum areas in Bangladesh in 2013 (DGHS, 2014)
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In Mymensingh state of Bangladesh the primary school children were about 15.1% wasted, 22.1% stunted, both stunted and wasted were about 2.3%, while about 60.4% children were normal (Hasan et al., 2013). In addition, Iodine deficiency disorder (IDD) is the most common disorder in Bangladesh. Normally, IDD affects pregnant women what might cause of irreparable brain impairment in the developing foetus. Consequently, new-borns and young children might cause brain damage, psychomotor, growth retardation, and intellectual impairment (FAO, 1999). FAO (1999) also stated that 53% children affected by Goitre, while hilly areas children were more likely vulnerable than other areas in Bangladesh. Furthermore, Vitamin-A Deficiency Disorder (VADD) is also common disorder among children in Bangladesh. Likewise, Iron Deficiency Anaemia (IDA) is the most common and acute problem of children. The prevalence of IDA was about 47% among pre-school children in Bangladesh (FAO, 2010).
Moreover, Ahmed et al. (2014) proposed that the prevalence of SAM was the highest in Asia. There are six countries in Asia, where more than 12 million children are suffering from SAM, partially about 0.6 million in Afghanistan, 0.6 million in Bangladesh, 8.0 million in India, 1.2 million in Indonesia, 1.4 million in Pakistan, and 0.6 million in Yemen (Ahmed et al., 2014).
Bangladesh is a small and Southeast Asian developing country in the world. Child malnutrition is high prevalent and there are many significant factors are involved of child malnutrition in Bangladesh. According to BDHS (2011), the most common and fundamental causes of child malnutrition including poverty, education, food insecurity, poor feeding and breast-feeding practice, poor demographic background, low socioeconomic status, parental smoking, and the presence of infectious diseases. Moreover, many researchers also found that the following risk factors which were significantly associated with child malnutrition in Bangladesh (Table 5):
Demographic factors were closely associated with child malnutrition. Rayhan and Khan (2006) proposed that demographic factors including sex of child, mother’s age at birth, number of living children, Birth order, earlier birth interval, size at new-borns baby, age of child, and mother’s BMI are significantly associated with child malnutrition. In addition, Jesmin et al., (2011) also reported that there was positive association between demographic factors and child malnutrition what might lead to the children become malnourished.
Low birth weight was the key determinants of child malnutrition. Ahmed et al. (2012) reported that birth weight of new-borns baby was crucial fact maintaining his or her healthy living. Low birth weight (below 2500g) directly leads to childhood malnutrition. Moreover, Bairagi and Chowdhury (1994) reported that birth order was also closely associated with children. This factor was the most common in Bangladesh and one in five children born with low birth weight in Bangladesh compare than any other countries in the world, while some progress have been initiated during the last couple of years due to health promotion policy, afterward the rate of low birth weight still highest in Bangladesh. According to table 4, about 43% of Bangladeshi children age group 0-59 months are adversely growth-rate stunted (Hong, Banta and Betancourt, 2006).
Table 4: Sample distribution and prevalence of stunting among children age 0-59 months by household wealth status and other selected characteristics, Bangladesh 2004 (Hong, Banta and Betancourt, 2006).
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