The current study highlights that the prevalence of stunting, wasting, and underweight declined by 4%, 6%, and 10%, respectively from 2014 to 2018. Between the earlier and later surveys, the prevalence of stunting declined less than the prevalence of wasting and underweight. The finding suggests that stunted children (in the first two years) may be chronically have a disadvantage to regain height later in childhood while wasting and underweight are acute cases often related to the inadequate quantity and quality of food [24]. Food insecurity and other insecurities cause emotional and physiological stress, and this can cause stunting [25]. However, the causes of undernutrition are multidimensional such as, immediate causes (inadequate dietary intake, acute disease), underlining causes (household food insecurity, unhealthy environment, inadequate healthcare service, and feeding practice), and basic causes (education, employment, income, technology, cultural, economic and political context) [26, 27]. This may create many challenges and take a long time in understanding the condition and finding solutions through interventions and policies. On the other hand, the prevalence of a minimum acceptable diet (MAD) increases from 23% in 2014 to 35% in 2018 in Bangladesh, which helped improve the condition of wasting and being underweight over time [16, 17].
One of the key findings of this study is approximately 3% of children under-5 experience coexistence of stunting, wasting, and underweight which can have a detrimental impact on their short- and long-term health. India reports a very high figure, with approximately one in ten children under-5 reporting coexistence of stunting, wasting, and underweight [28]. Compared to other poor-income countries like Malawi (2%) and Ethiopia (4%) [29, 30], the prevalence of coexistence of stunting, wasting, and underweight is high in Bangladesh. Limited resources at the National Nutrition Services (NNS) in Bangladesh may result in limited coverage and quality of interventions. Frequent changes in leadership, coordination, capacity, and workload-related challenges the NNS face have hampered the implementation of nutrition interventions [31]. However, we observed the coexistence of stunting, wasting, and underweight among children declined 2% in 2017/18 from 5% in 2014, indicating that current interventions might be effective. Therefore, leadership, stability, and resources at the NNS can provide further coverage of high-quality interventions further to decrease the coexistence of stunting, wasting, and underweight in children under-5.
This study found that the relative risk of coexistence of stunting, wasting, and underweight increased by 130% in children with low birth weight compared to normal weight. Children with low birth weight experience growth failure during early childhood, increasing the risk of long-term complications like diarrheal and lower respiratory infections, sleep apnea, jaundice, anemia, chronic lung disorders, fatigue, and loss of appetite [20]. Low birth weight was a risk factor for the coexistence of stunting, wasting, and underweight, and our results concur with Ramakrishnan (2004) [32]. Children of the older age group (36–47 months) had a 2.5 times higher risk of coexistence of stunting, wasting, and underweight than the youngest children (less than 1 year). Das and Gulshan (2017) found older children had a high risk of stunting ((odds ratio (OR): 1.5)) and a lower risk of wasting in Bangladesh [33]. In that case, the estimated risk of the coexistence of stunting, wasting, and underweight among older children was higher compared to previous study findings. After the second year of life, children in Bangladesh tend to have the same diet as the family and breast milk. However, they are often allowed to eat the food themselves, and they do not always have access to adequate amounts of solid food, which might contribute to several anthropometric failure, such as, stunting, wasting or underweight [34]. Poorer socioeconomic status [3] is another risk factor that contributes coexistence of stunting, wasting, and underweight, and our findings concur, demonstrating the complex nature of this public health issue.
The risk of having coexistence of stunting, wasting, and underweight increased by 98% in children of mothers with no formal education. Lack of maternal education was assessed as an influential risk factor for child stunting, wasting, or underweight in previous studies in Bangladesh and other developing countries [8, 35,36,37]. Current evidence also showed 5% of children of mothers with no formal education were suffering from the coexistence of stunting, wasting, and underweight. The parallel state of poor maternal educational and socio-economic status in households might affect children with critical nutritional hazards due to knowledge gaps and the inability to provide an appropriate diet [38]. Also, the coexistence of stunting, wasting, and underweight among children increased by 95% for those born to underweight mothers. Likely because mothers are malnourished due to the emotional and physiological impact of food insecurity, poverty, and micronutrient deficiencies [39]. Investing in the maternal and child healthcare system, and increasing the participation of underprivileged people in income-generating activities can improve the nutritional status of children as well as other physical development. Further, improving women's education can increase family income and access to a better quality of diet, consequently improving children's health [40]. Increasing education opportunities for females, especially in rural areas, is recommended [8].
The study findings also showed that a higher incidence of coexistence of stunting, wasting, and underweight was observed in children in the 2014 BDHS survey (children born between 2009 and 2014) than those in the 2017–18 survey (children born between 2014 and 2017). Nutritional changes include a rise in household assets, improvements in parental education, food security, and increasing dietary diversity. It also consists of reducing open defecation, improvements in prenatal and birth delivery care, family reproductive factors (birth order and birth intervals), maternal height and weight, and increasing agricultural production. GO-NGO-led nutritional programs might significantly reduce the incidence of coexistence of stunting, wasting, and underweight [41]. However, the country still faces significant challenges in providing equitable access to health, nutrition, and population services.
This study also suggests some policy implications and interventions to prevent and treat the coexistence of stunting, wasting, and underweight. Routine national and subnational level nutrition surveys such as demographic health surveys (DHS) and Multiple Indicator Cluster Surveys (MICSs) need to be modified to include the coexistence of stunting, wasting, and underweight to inform the program policy decision-making. Routine monitoring of the prevalence of coexistence of stunting, wasting, and underweight would be required to inform effective detection and treatment [42]. Community engagement and coexistence of stunting, wasting, and underweight screening could also be expanded in innovative methods by enrolling additional expertise and resources [43]. Innovative and early markers should be developed to predict, identify, and monitor children at short-term and long-term consequences due to the coexistence of stunting, wasting, and underweight [44]. Maternal factors from adolescence through pregnancy need to be searched that adversely affect utero and postnatal child who is living with stunting, wasting, and underweight [44]. Therapeutic interventions (e.g., ready-to-use therapeutic foods) must be reviewed and adjusted to ensure that the children at the highest mortality risk due to the coexistence of stunting, wasting, and underweight are included. Comprehensive nutrition programmes must be developed to pursue Sustainable Development Goal (SDG) 2.2, to end stunting, wasting, and underweight by 2030 [41].
The use of multiple nationally representative household survey data points with a high response rate was the strength of this study. The survey questions were validated and established. Although suitable statistical tools like Negative Binomial Regression were used to assess the risk factors, the cross-sectional nature of the data was not sufficient to establish a causal relationship between risk factors and the dependent variables. Further, data on potential confounders like diet, food insecurity, and parental smoking behavior were unavailable Child’s birth size from mothers’ recall was used as a proxy of actual measurement of size at birth due to unavailability of measure data in BDHS, and thus should be used with caution. The BDHS data were collected retrospectively and self-reported; underreporting, information bias, and recall bias might be possible.