Large declines in under-nutrition alongside striking increases in obesity among children in Bangladesh

In the last two decades there has been a major reduction in undernutrition and a considerable increase in obesity in children in Bangladesh, creating a dual burden of poor nutrition

The proportion of underweight malnourished children has declined by 53% in urban Bangladesh since 1993, and by 47% in rural areas since 2000. These are the results of a new icddr,b study that used 19 years of demographic surveillance data to identify the changing risk factors behind childhood undernutrition.  A total of 40 349 children under five years of age were enrolled in the surveillance system at icddr,b’s Dhaka Hospital and Matlab field sites between 1993 and 2012. The team of scientists, led by Dr Sumon Kumar Das, an assistant scientist with icddr,b’s Centre for Nutrition and Food Security, attributes this positive trend to an overall reduction in poverty, an improvement in sanitation and the introduction of nutritional interventions by the Government of Bangladesh and non-governmental organisations, among other factors.

However, the results also show that child obesity is on the rise in Bangladesh, and the scientists warn about the dangerous relationship between overnutrition (obesity) and undernutrition in developing countries.

According to the World Health Organization, childhood malnutrition—when a child is underweight, stunted or wasted—contributes to more than a third of all child deaths, and among survivors can have a considerable and long-lasting impact on cognitive development and economic potential. It is related to poor diet and health, and has been linked to chronic diarrhoeal disease during early childhood.

 Photo: © icddr,b / Shumon Ahmed

But this new study shows that the risk factors for malnutrition have changed significantly since the 1990s. For example, among children aged 12 to 23 months in urban Dhaka in 1993, wasting was strongly associated with maternal illiteracy, a family size of more than five, slum residence, a monthly income of USD $100 or less and the use of untreated drinking water. By 2012, however, only a child’s older childhood age and maternal illiteracy had a positive association with wasting.

The substantial improvements in nutritional status shown by the data can be explained by several factors, say the scientists. Maternal illiteracy has improved due in part to the implementation of microcredit programmes that created substantial opportunities for women’s self-employment, thereby raising household income and liberating women in poor families. High immunisation coverage, better maternal and childhood feeding practices, the use of nutritional interventions such as micronutrient powder distribution and home gardening also help improve child nutrition

Strikingly, however, the data also show growing rates of child overweight and obesity. In rural Matlab, the proportion of children under five years of age who are overweight and obese more than doubled between 2000 and 2012. The scientists speculate this could be due to a lack of physical activity as a result of unplanned urbanization and sedentary lifestyles, and increased consumption of foods with high amounts of fat, sugar and salt. Increasingly, the diets of people in developing countries consist of food with a high energy density but low micronutrient content, say the authors.

Other recent icddr,b studies exploring nutrition trends in Bangladesh confirm that overweight and obesity are serious public health threats, especially among children. While the systematic analysis of national prevalence for overweight and obese adults and children in Bangladesh for the Global Burden of Disease Study 2013 found that less than 2% of the population is obese, a separate scoping review of the literature found that the prevalence could actually range from 1% to 17.9%, depending on the reference standard. The two studies agree there is an increase in childhood obesity over time, with a higher prevalence amongst urban children.

Indeed, another recent icddr,b study, which looked at the urban-rural divide in childhood nutrition, found that almost 20% of rural children are still underweight, and therefore at a higher risk for diarrhoeal diseases and infection, while 5.6% of urban children are now obese,  and therefore susceptible to diabetes, metabolic disorders and heart problems in later life.

What this means is that existing public health policy in Bangladesh is likely no longer sufficient to deal with the double burden of communicable and non-communicable diseases facing Bangladeshi children. India, Bangladesh’s middle-income neighbour and malnutrition contemporary, is already the third most obese country in the world by population. To prevent this epidemic from engulfing Bangladesh, Dr Das and his colleagues recommend that the trends identified in their paper be used by the Government of Bangladesh and non-governmental organisations to guide future programmes and policies on nutrition.