Khan et al.

BMC Nutrition (2016) 2:69

DOI 10.1186/s40795-016-0112-4

RESEARCH ARTICLE Open Access

Prevalence and associated factors of

malnutrition among children under-five
years in Sindh, Pakistan: a cross-sectional
study
Gul Nawaz Khan1, Ali Turab1, Mohammad Imran Khan2, Arjumand Rizvi1, Fariha Shaheen1, Asmat Ullah1,
Amjad Hussain1, Imtiaz Hussain1, Imran Ahmed1, Muhammad Yaqoob1, Shabina Ariff1 and Sajid Bashir Soofi1*

Abstract
Background: Globally, malnutrition accounts for at least half of all childhood deaths. Managing malnutrition in the
community settings involves identifying malnutrition using a universally validated screening tool and implementing
appropriate interventions according to the degree of malnutrition. The aim of this study was to estimate prevalence
and associated factors that result in malnutrition among children under-five years of age in Thatta and Sujawal
districts in Sindh province, Pakistan.
Methods: A cross-sectional survey was conducted between May and August 2014. A total of 3964 children under-
five years were enrolled in the study. The WHO growth standards height-for-age Z-scores (HAZ), weight-for-height
Z-scores (WHZ) and weight-for-age Z-scores (WAZ) were used to measure stunting, wasting and underweight. A
structured questionnaire was used to collect data on socioeconomic conditions, family size, maternal education,
parity and child morbidity. Multivariable logistic regression was used to determine the risk factors for malnutrition.
Results: The prevalence of stunting, wasting and underweight were 48.2% (95% CI: 47.1–50.3), 16.2% (95% CI: 15.5–17.
9), and 39.5% (95% CI: 38.4–41.5), respectively. Stunting was slightly higher (51%) in boys than in girls (45%) (p < 0.001).
The proportion of wasting (p = 0.039) and underweight (p = 0.206) was not significantly different between boys and
girls. Fifty percent children in the poorest households were stunted as compared to 42% in the wealthiest households.
Children in the poorest households were two times more likely to be wasted (20.6%) than children in the
wealthiest households (10.3%) (OR 2.33, CI 1.69–3.21, p < 0.001). A similar relationship was observed between
household wealth and underweight in children (43.8% in poorest and 28.8% in wealthiest households (OR 2.18,
CI 1.72–2.77, p < 0.001). Household wealth was significantly associated with stunting, wasting and underweight.
Diarrhea was associated with underweight. Factors such as mother’s education, parity and family size were not
associated with malnutrition in our study area.
Conclusions: The findings of our study revealed that malnutrition was widespread among the children under-
five years of age. The food/nutrient based interventions together with improved hygiene practices and
household wealth should be targeted to improve malnutrition situation in the study area and in the country.
Keywords: Malnutrition, Prevalence, Children, Stunting, Wasting, Underweight

* Correspondence: [email protected]
1
Department of Paediatrics and Child Health, Aga Khan University, Karachi,
Pakistan
Full list of author information is available at the end of the article

© The Author(s). 2016 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Khan et al. BMC Nutrition (2016) 2:69 Page 2 of 7

Background (35%), roofing (36%) and walls (40%). Individuals in the

Globally in 2014, an estimated 159 million children poorest wealth quintiles own more than 50% of house-
under-five years were stunted, 95 million were under- holds, while only 3% of households belong to individuals
weight and 50 million were wasted [1]. Malnutrition ac- in the richest wealth quintiles [20].
counts for at least half of all childhood deaths worldwide
[2, 3]. Despite the economic development, childhood Sample size
malnutrition still remains a major public health problem Sample size was calculated using comparison of two se-
in developing countries [2, 4, 5]. Contributing factors in quential surveys approach to assess the impact of inter-
childhood malnutrition are intra-uterine growth retard- vention over time as discussed in Micronutrient Initiative
ation, low birth weight, inadequate exclusive breast feed- (MI) and United States Center for Disease Control (CDC)
ing, inappropriate complementary feeding, maternal manual [21]. Sample size calculation considered the
education, low nutritional knowledge, insufficient energy prevalence of stunting in Sindh province at 49% (NNS
and micronutrient intake, birth spacing, parity, socio- 2011) and design effect of 2. Total sample size required
economic background, food availability, housing, poor was 3964 per survey to detect 10% difference with 80%
sanitation, health services, vaccination and infectious power and 5% level of significance.
diseases [5–15].
The Islamic Republic of Pakistan is among the coun- Sampling methodology
tries in the world with the highest rates of child malnu- A two-staged cluster sampling technique was used to
trition (Stunting 44%, Wasting 15% & underweight 31%) select households for interviews. In the first stage,
and its progress in child nutrition and health remained sample size was divided in 29 UCs using a Proportion to
slower than in other South Asian countries [16–18]. The Population Size (PPS) design. In the second stage,
data obtained from the National Nutrition Survey (NNS)
2011 indicated little change over the last decade in terms
of childhood nutrition indicators. Among children
under-five, 44% were stunted in 2011 as compared to Table 1 Socio-demographic characteristics of the sample
41% in the 2001. Fifteen-percent were wasted compared population
to 14% in 2001 and 31% were underweight, which has Indicators n Percent
not changed since 2001. The malnutrition rates were Gender
relatively lower in urban areas compared to rural areas Male 2025 51.1
in Pakistan [19]. This paper presents the results of base- Female 1939 48.9
line data of a large project on effectiveness of food/nutri- Age in months (Mean ± SD) 22.81 ± 15.23
ent based interventions to prevent stunting among
< 6 months 602 15.2
children under-five years in districts Thatta and Sujawal,
Sindh province, Pakistan. 6–11 months 645 16.3
12–23 months 828 20.9
Methods 24–35 months 1041 26.3
Study design 36–47 months 529 13.3
A cross-sectional survey design was used to collect data 48–59 months 319 8
between May and August 2014. The survey was designed
Mother’s education
to provide baseline information on a representative sam-
ple of households in the study area. No formal education 3439 87.9
Primary 348 8.9
Study setting Secondary/Higher 125 3.2
The study was conducted in 29 Union Councils (UCs) of Parity 1.49 ± 0.73
Thatta and Sujawal districts in Sindh, Pakistan. These 1 2349 59.8
districts are located in the southern part of the Sindh
2 1237 31.5
province. They are administratively subdivided into 9
Talukas and 55 UCs with a population of 1.5 million. 3 278 7.1
According to the 2014 Multiple Indicators Cluster >4 66 1.7
Survey (MICS) conducted in Sindh, more than 88% of Family size 6.7 ± 2.8
the population in Thatta and Sujawal have access to im- 1–5 1552 39.2
proved sources of drinking water, 68% have access to 6–10 2053 51.8
electricity, and 31% of households own agriculture land.
> 10 359 9.1
Furthermore, few of the households have finished floors
Khan et al. BMC Nutrition (2016) 2:69 Page 3 of 7

Table 2 Prevalence of stunting in children under-five years of seca-213 used for height measurement, seca-210 measur-
age ing mat for measuring the length and MUAC tape for
N Stunted Mean Z- children with three colours of thresholds at red to
score (SD) 115 mm, yellow 115–125 mm and green from 125 mm
(<−2 z-score) (<−3 z-score)
All children 3903 48.2 (47.1–50.3) 23.9 (22.6–25.3) −1.92 (1.53) was used. We measured length for children <24 months
Sex
and height for children 24–59 months according to WHO
standards [22]. The measurements were obtained by two
Boys 1993 51.3 (49.4–53.8) 25.5 (23.6–27.4) −1.99 (1.55)
trained anthropometrists. The date of birth was reported
Girls 1910 45.1 (43.4–47.8) 22.3 (20.4–24.2) −1.83 (1.51) by the mother and verified by birth certificates and vaccin-
Age group ation cards. Sixteen enumerators, 4 team leaders, 2 desk
0–5 months 588 21.9 (18.7–25.4) 9.7 (7.3–12.1) −0.97 (1.58) editors and 2 field supervisors were hired, trained and
6–11 months 639 34.3 (31.0–38.4) 14.9 (12.1–17.6) −1.37 (1.66) involved in baseline data collection.
12–23 months 815 56.2 (53.4–60.2) 27.9 (24.7–30.9) −2.15 (1.4)
Statistical analysis
24–35 months 1027 59.9 (57.4–63.4) 32.9 (30.0–35.8) −2.38 (1.34)
Three anthropometric indicators were constructed on
36–47 months 519 62.6 (59.0–67.3) 28.7 (24.8–32.6) −2.35 (1.37) height-for-age (HAZ), weight-for age (WAZ) and weight-
48–59 months 315 43.5 (38.3–49.3) 21.6 (17.0–26.1) −1.97 (1.25) for-height (WHZ) in the form of z-scores using WHO
Anthro 2006 software. Each z-score depicts the deviation
from the median height or weight of a child of the
villages and households with children under-five years same age and sex in the reference population. Stunt-
were randomly selected for interview. ing was defined as height-for- age (Z-score < −2),
wasting as weight-for-height (Z-score < −2), and under-
Data collection weight as weight-for-age (Z-score < −2) using child growth
A structured household survey questionnaire was used to standards published by the World Health Organization
collect data through face-to-face interviews from mothers. (WHO) in 2006 [22]. WHO Anthro 2006 software by
The information collected included socio-economic and default flagged missing data and implausibly high or low
demographic characteristics, food insecurity, morbidity observations. Hence total 2.9% of the observations were
and child anthropometric measurements. Questionnaire eliminated due to flagging.
was tested during the field testing and changes were incor- The study population’s characteristics were summa-
porated accordingly. The questionnaire was initially de- rized using means with standard deviations (SD) for the
signed in English, translated in Sindhi by senior project continuous variables and percentages for the categorical
team member and then back-translated to English by an variables. Confidence intervals were also reported for
independent person to check for inconsistencies. Weight, inference.
length or height and mid-upper arm circumference Predictors of childhood malnutrition (stunting, wast-
(MUAC) were measured using standard anthropometric ing, under-weight and all three) were investigated using
methods. Seca-874 was used for weight measurement, logistic regression analysis. A range of child, maternal

Table 3 Prevalence of wasting in children under-five years of age

N Wasted Overweight Mean Z-
score (SD)
<−2 SD <− 3 SD >2 SD >3 SD
All children 3906 16.2 (15.5–17.9) 5.4 (5.0–6.5) 2.5 (2.1–3.2) 0.6 (0.5–1.0) −0.76 (1.34)
Sex
Boys 1997 16.8 (15.9–19.2) 5.5 (5.1–7.2) 2.7 (2.1–3.5) 0.8 (0.4–1.2) −0.79 (1.37)
Girls 1909 15.5 (14.1–17.4) 5.2 (4.5–6.5) 2.3 (1.8–3.2) 0.5 (0.3–1.1) −0.74 (1.32)
Age group
0–5 months 581 11.2 (9.3–14.5) 4.3 (3.3–6.9) 8.1 (6.2–10.7) 1.9 (1.1–3.6) −0.23 (1.56)
6–11 months 638 16.8 (14.3–20.1) 4.7 (3.5–7.0) 3.1 (2.0–4.8) 0.6 (0.2–1.7) −0.67 (1.39)
12–23 months 822 15.7 (13.9–19.0) 5.2 (4.0–7.1) 1.8 (0.9–2.9) 0.6 (0.1–1.3) −0.85 (1.26)
24–35 months 1032 20.8 (18.5–23.5) 7.1 (5.6–8.7) 0.7 (0.1–1.2) 0.1 (0.09–0.3) −1.03 (1.26)
36–47 months 518 14.7 (12.2–18.4) 5.6 (4.2–8.4) 1.4 (0.3–2.3) 0.4 (0.24–1.5) −0.79 (1.27)
48–59 months 315 12.4 (9.5–16.9) 3.2 (1.7–5.9) 0.6 (0.1–2.0) 0.3 (0.24–1.5) −0.79 (1.09)
Khan et al. BMC Nutrition (2016) 2:69 Page 4 of 7

Table 4 Prevalence of underweight in children under 5 years Results

of age Socio-demographic characteristics
N Underweight Mean Z- Socio-demographic characteristics of the sampled children,
score (SD) their mothers and households are presented in Table 1.
(<− 2 SD) (<− 3 SD)
All children 3939 39.5 (38.4–41.5) 14.6 (13.5–15.7) −1.68 (1.31) Mother’s educational levels were relatively low and 88% of
Sex
mothers were not formally educated. We collected data for
3964 children, among them 51% were males and 49% were
Boys 2011 40.2 (38.5–42.8) 15.3 (13.7–16.8) −1.73 (1.31)
females. Fifty-two percent children were under the age of
Girls 1928 38.7 (37.1–41.4) 14.0 (12.4–15.5) −1.64 (1.32) two years, while 48% children were between age of 2–5
Age group years. About 40% of children had two or more siblings in
0–5 months 596 21.6 (18.5–25.1) 9.4 (7.1–11.7) −0.96 (1.47) the selected households. More than half of households had
6–11 months 642 28.3 (25.0–32.0) 11.4 (8.9–13.8) −1.35 (1.46) 6–10 family members, while 9% had more than ten family
12–23 months 822 41.0 (38.2–44.9) 14.2 (11.8–16.6) −1.74 (1.23)
members.
24–35 months 1035 51.6 (49.2–55.3) 18.7 (16.4–21.1) −2.06 (1.11)
36–47 months 527 48.4 (44.9–53.4) 19.2 (15.8–22.5) −2.02 (1.16)
Prevalence of stunting
The prevalence of stunting in the study sample was
48–59 months 317 37.5 (32.5–43.2) 11.0 (7.6–14.5) −1.77 (1)
48%, and was slightly higher (51%) in boys than in
girls (45%). Similarly, severe stunting rates were
and household level factors were included in the model- slightly higher in boys (25.5%) than in girls (22.3%).
ling such as child age and gender, maternal education Stunting rates gradually increased from 22% in children
and parity, family size and wealth index. Wealth index is a <5 months old to 62.6% in children 36–47 months old,
composite score constructed with broad range of socio- however it reduced in children 48 to 59 months (43.5%)
economic indicators including household construction [Table 2].
material, source of drinking water and sanitation facilities,
household utilities and assets using principal component
analysis. This score further divided in 5 equal categories Prevalence of wasting
comprising 20% of the data in each category [23]. The prevalence of wasting in the study area was 16.2%.
Univariate analysis was conducted to determine inde- Proportion of wasting among boys and girls was not
pendent effect of each predictor on outcomes. Then all prominent. Wasting increased with age, peaking at
predictors were included in multivariate analysis to in- 20.8% among children in 24–35 months of age. Only
vestigate net effect of each predictor on outcomes 2.5% children were overweight [Table 3].
adjusting for all other factors in the model. Adjusted OR
were calculated to study the predictive power of inde- Prevalence of underweight
pendent study variables in relation to childhood malnu- Overall, 39.5% of children under the age of five years were
trition. All statistical analyses were performed using underweight. Prevalence of underweight for both sexes
SPSS version 15.0 with the statistical significance set at a was almost same. The rates of underweight increased with
p value ≤ 0.05. age, peaking at 51.6% among children in 24–35 months of

Fig. 1 Comparison of underweight, stunting and wasting by wealth quintiles

Khan et al. BMC Nutrition (2016) 2:69 Page 5 of 7

Table 5 Results of multivariable logistic regression analysis showing determinants of malnutrition

Variables Stunting Wasting Under-weight All three outcomes
OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value OR (95% CI) p-value
Gender
Boys 1.30 (1.14–1.49) <0.0001 1.20 (1.01–1.43) 0.039 1.09 (0.95–1.25) 0.206 1.29 (1.02–1.65) 0.037
Girls Ref.
Age
< 6 months Ref.
6–11 months 1.93 (1.49–2.51) <0.0001 1.43 (1.03–1.99) 0.033 1.39 (1.06–1.81) <0.0001 3.17 (1.72–5.85) <0.0001
12–23 months 4.93 (3.86–6.30) <0.0001 1.41 (1.03–1.94) 0.032 2.64 (2.07–3.38) <0.0001 4.99 (2.79–8.90) <0.0001
24–35 months 5.66 (4.45–7.20) <0.0001 1.93 (1.43–2.60) 0.000 4.30 (3.39–5.47) <0.0001 4.23 (2.37–7.53) <0.0001
36–47 months 6.90 (5.21–9.13) <0.0001 1.30 (0.91–1.87) 0.151 4.17 (3.16–5.49) <0.0001 3.96 (2.11–7.43) <0.0001
48–59 months 2.99 (2.19–4.10) <0.0001 1.15 (0.75–1.77) 0.516 2.51 (1.82–3.45) <0.0001 2.30 (1.09–4.85) 0.029
Mother’s education
No formal education 0.93 (0.62–1.40) 0.730 0.94 (0.53–1.70) 0.847 0.72 (0.48–1.09) 0.121 0.97 (0.42–2.22) 0.936
Primary 0.74 (0.47–1.15) 0.180 0.71 (0.37–1.36) 0.300 0.55 (0.35–0.86) 0.010 0.61 (0.23–1.57) 0.302
Secondary /Higher Ref.
Parity
1 Ref.
2 1.07 (0.92–1.26) 0.378 1.01 (0.83–1.23) 0.936 1.19 (1.02–1.40) 0.029 0.97 (0.73–1.28) 0.823
3 1.24 (0.93–1.65) 0.137 1.00 (0.69–1.45) 0.987 1.41 (1.06–1.88) 0.018 1.23 (0.75–2.01) 0.412
>4 1.41 (0.81–2.46) 0.221 0.87 (0.40–1.91) 0.733 1.16 (0.65–2.06) 0.623 0.97 (0.33–2.87) 0.961
Family size
1–5 Ref.
6–10 1.04 (0.90–1.20) 0.594 0.99 (0.82–1.19) 0.883 0.97 (0.84–1.12) 0.663 0.95 (0.74–1.23) 0.725
> 10 1.02 (0.79–1.33) 0.862 1.16 (0.83–1.62) 0.391 1.00 (0.77–1.30) 0.987 1.13 (0.72–1.80) 0.590
Wealth quintiles
Lowest 1.49 (1.18–1.88) 0.001 2.33 (1.69–3.21) <0.0001 2.18 (1.72–2.77) <0.0001 2.31 (1.47–3.64) <0.0001
Second 1.52 (1.20–1.91) 0.000 2.01 (1.45–2.77) <0.0001 2.11 (1.66–2.68) <0.0001 2.07 (1.31–3.27) 0.002
Middle 1.37 (1.09–1.73) 0.006 1.74 (1.26–2.41) <0.0001 1.73 (1.36–2.19) <0.0001 1.82 (1.15–2.88) 0.010
Fourth 1.30 (1.04–1.62) 0.022 1.40 (1.01–1.94) <0.0001 1.67 (1.32–2.10) <0.0001 1.45 (0.91–2.31) 0.115
Highest Ref.
Morbidity
Diarrhea 1.13 (0.97–1.33) 0.124 1.18 (0.97–1.45) 0.099 1.36 (1.16–1.59) <0.0001 1.27 (0.97–1.67) 0.084
ARI 0.99 (0.82–1.19) 0.883 0.94 (0.74–1.19) 0.617 0.98 (0.82–1.19) 0.871 0.84 (0.60–1.17) 0.306

age, and then dropped to 37.5% among children in 48–59 poorest households were two times more likely to be
months of age [Table 4]. wasted (20.6%) compared to children in the wealthi-
est households (10.3%). A similar relationship was ob-
Association of malnutrition with wealth quintiles served between household wealth and underweight in
Figure 1 presented comparison of underweight, stunt- children (43.8% in poorest and 28.8% in wealthiest
ing and wasting rates by wealth quintiles. The preva- households) in the study area.
lence of underweight, stunting and wasting was Multiple malnutrition (stunting, wasting and under-
higher in children of poorest households than in chil- weight) was higher in boys than girls. Children aged
dren of wealthiest households. Fifty percent children between 12 and 23 months were in more risk for being
in the poorest households were stunted compared to stunted and underweight than in other age groups
42% in the wealthiest households. Children in the [Tables 2 and 4].
Khan et al. BMC Nutrition (2016) 2:69 Page 6 of 7

Determinants associated with malnutrition higher child undernutrition in Bangladesh, Ethiopia, and
Determinants related to stunting, wasting and under- Vietnam [32] but not associated with child undernutri-
weight presented in Table 5. Determinants such as tion in a study from rural Cambodia [33].
mother’s education, parity and family size was not asso-
ciated with stunting, wasting and underweight; while Conclusions
gender, age and wealth quintiles was associated with The findings of our study revealed that malnutrition was
malnutrition. Diarrhea was associated with underweight. widespread among the children under-five years. House-
The p-value of stunting in boys was highly significant hold wealth was highly associated with all three forms of
<0.0001 relative to girls, but it was not significant for nutritional outcomes. To succeed in the reduction of
wasting and underweight in the study area. child malnutrition in the study area and in Pakistan,
interventions must target short term nutrition supple-
Discussion ments and long term economic empowerments of poor
This study was conducted to provide baseline results for a communities. Further research is recommended to inves-
large trial for the effectiveness of food/nutrient based in- tigate potential factors associated with child malnutrition,
terventions to prevent stunting among children under-five and interventions to improve nutritional status in children
years in Thatta and Sujawal districts of Sindh province, under-five years.
Pakistan. The findings of our study revealed that malnutri-
Abbreviations
tion was widespread among the children under-five year CDC: Center for Disease Control; CI: Confidence intervals; ERC: Ethical review
old, and has not improved since last two decades [19]. committee; HAZ: Height-for-age z-scores; MI: Micronutrient Initiative;
The study data provide critical information on child nutri- MUAC: Mid-upper arm circumference; NBC: National Bio-Ethics Committee;
NNS: National Nutrition Survey; OR: Odds ratio; PDHS: Pakistan Demographic
tion, health, household wealth quintiles, family size, parity Health Survey; PPS: Proportion to Population Size; SD: Standard deviation;
and food security in the sampled population. UCs: Union Councils; WAZ: Weight-for-age z-scores; WHO: World Health
Stunting prevalence found in this study area was Organization; WHZ: Weight-for-height z-scores
48.2% and is considered as ‘Very High’ public health sig-
Acknowledgments
nificance according to WHO standards. The prevalence We are grateful to the staff of health department and study participants for
of stunting was slightly higher (51%) in boys than in girls their time and contribution. We would like to appreciate all staff of the study
for their hard work and support provided by DMU, Aga Khan University,
(45%). These findings are comparable with national
Pakistan.
results reported in PDHS 2012–13 [19] and in a meta-
analysis for sub-Saharan Africa studies [24]. Funding
The rapid increase in stunting between 6 and 24 months This study was financially supported by World Food Programme (WFP),
Pakistan.
of life (from 34 to 56%) in the study area is particularly
concerning. This is the “window of opportunity” as well to Availability of data and materials
prevent stunting during the pregnancy and the first 2 years Data will be available upon request to corresponding author.
of life of the child, cumulating a critical period for inter- Authors’ contributions
vention of 1000 days. Unfortunately, after two years of SBS conceptualized the study, its design and analysis plan. SBS, GNK, AT, AU, IH
age, it is extremely difficult to intervene and catch-up and MY were involved in implementation of the study. GNK wrote first and
subsequent drafts, participated in data acquisition and data analysis plan. AR
growth, leading to irreversible damages in the develop- and FS participated in data analysis. AH, IA, AU, SA and GNK involved in data
ment of the child. management. MIK and AT edited the manuscript. All authors reviewed and
The results of our study also revealed that there approved the content of the final manuscript.
was a highly significant chance for being of stunted, Competing interests
wasted and underweight in children belonging to the The authors declare that they have no competing interests.
lower quintiles as compared to highest quintiles, and
almost similar findings were reported in three studies Consent for publication
Not applicable.
from Africa [25–27].
Research studies had identified maternal education Ethics approval and consent to participate
higher than primary school, as one of the main factors of The study was reviewed and approved by Ethical Review Committee (ERC) of
Aga Khan University and National Bio-Ethics Committee (NBC) of Pakistan.
childhood malnutrition [27–30]. As many women in our Informed written consent was obtained from parents of each study participant
study area were illiterate and we anticipate that maternal to participate in the study and all the data was kept confidential.
education had limited implications for inter-household
Author details
differences in nutrition, and similar finding were reported 1
Department of Paediatrics and Child Health, Aga Khan University, Karachi,
in a study from Democratic Republic of Congo [31]. Pakistan. 2Center of Excellence in Women and Child Health, Aga Khan
Household food insecurity was also positively associ- University, Karachi, Pakistan.
ated with wasting but not with stunting and underweight Received: 7 September 2016 Accepted: 18 November 2016
in our study area. Food insecurity was associated with
Khan et al. BMC Nutrition (2016) 2:69 Page 7 of 7

References 26. Van Den B, Ettyang GB, Keino S, Plasqui G. Determinants of stunting and
1. UNICEF/WHO/World Bank. Joint Child Malnutrition Estimates by UNICEF, overweight among young children and adolescents in sub-Saharan Africa.
WHO & World Bank. 2014. http://data.worldbank.org/child-malnutrition. Food Nutr Bull. 2014;35:167–78.
2. Demissie S, Worku A. Magnitude and factors associated with malnutrition in 27. Hong R. Effect of economic inequality on chronic childhood undernutrition
children 6–59 months of age in Pastoral community of Dollo Ado District, in Ghana. Public Health Nutr. 2007;10:371–8.
Somali Region, Ethiopia. Sci J Public Health. 2013;1:175–83. 28. Fotso JC. Child health inequities in developing countries: differences across
3. Meshram II, Arlappa N, Balakrishna N, Rao KM, Laxmaiah A, Brahmam GNV. urban and rural areas. Int J Equity Health. 2006;5:9.
Trends in the prevalence of undernutrition, nutrient and food intake and 29. Fotso JC. Urban–rural differentials in child malnutrition: trends and
predictors of undernutrition among under five year tribal children in India. socioeconomic correlates in sub-Saharan Africa. Health Place. 2007;13:205–23.
Asia Pac J Clin Nutr. 2012;21:568–76. 30. Kumar A, Kumari D. Decomposing the Rural–urban Differentials in Childhood
4. Masibo PK, Makoka D. Trends and determinants of undernutrition among Malnutrition in India, 1992–2006. Asian Popul Stud. 2014;10:144–62.
young Kenyan children: Kenya Demographic and Health Survey; 1993, 1998, 31. Kismul, et al. The social context of severe child malnutrition: a qualitative
2003 and 2008–2009. Public Health Nutr. 2012;15:1715–27. household case study from a rural area of the Democratic Republic of
5. Pasricha SR, Biggs BA. Undernutrition among children in South and South- Congo International. J Equity Health. 2015;14:47.
East Asia. J Paediatr Child Health. 2010;46:497–503. 32. Disha A, Kuntal KS, Phuong HN, Michael TD, Marie TR, Purnima M, et al.
6. Jesmin A, Yamamoto SS, Malik AA, Haque A. Prevalence and determinants Household food insecurity is associated with higher child undernutrition
of chronic malnutrition among preschool children: a cross-sectional study in Bangladesh, Ethiopia, and Vietnam, but the effect is not mediated by
in Dhaka City, Bangladesh. J Health Popul Nutr. 2011;29:494–9. child dietary diversity. J Nutr. 2013;143:2015–21.
7. Pruss-Unstun A, Bos R, Gore F, Bartram J. Safer water, better health: costs, 33. McDonald CM, McLean J, Kroeun H, Talukder A, Lynd LD, Green TJ. Household
benefits and sustainability of interventions to protect and promote health. food insecurity and dietary diversity as correlates of maternal and child
Geneva: WHO; 2008. undernutrition in rural Cambodia. Eur J Clin Nutr. 2015;69(2):242–6.
8. Lozano R, Naghavi M, Foreman K, Lim K, Shibuya K, Aboyans, et al. Global
and regional mortality from 235 causes of death for 20 age groups in 1990
and 2010: a systematic analysis for the Global Burden of Disease Study
2010. Lancet. 2012;380:2095–128.
9. Boschi-Pinto C, Velebit L, Shibuya K. Estimating child mortality due to diarrhoea
in developing countries. Bull World Health Organ. 2008;86:710–7.
10. Guerrant RL, DeBoer MD, Moore SR, Scharf RJ, Lima AAM. The impoverished
gut—a triple burden of diarrhoea, stunting and chronic disease. Nat Rev
Gastroenterol Hepatol. 2013;10:220–9.
11. Ferriman A. BMJ readers choose the “sanitary revolution” as greatest medical
advance since 1840. BMJ. 2007;334:111.
12. Esrey SA, Potash JB, Roberts L, Shiff C. Effects of improved water supply and
sanitation on ascariasis, diarrhoea, dracunculiasis, hookworm infection,
schistosomiasis, and trachoma. Bull World Health Organ. 1991;69:609–21.
13. Wolf J, Prüss-Ustün A, Cumming O, Bartram J, Bonjour S, Cairncross S, et al.
Assessing the impact of drinking water and sanitation on diarrhoeal disease
in low- and middle-income settings: systematic review and meta-regression.
Trop Med Int Health. 2014;19(8):928–42.
14. Clasen TF, Bostoen K, Schmidt WP, Boisson S, Fung IC, Jenkins MW, et al.
Interventions to improve disposal of human excreta for preventing diarrhoea.
Cochrane Database Syst Rev. 2010;6:CD007180.
15. Engell RE, Lim SS. Does clean water matter? An updated analysis of water supply
and sanitation interventions and diarrhoeal diseases. Lancet. 2013;381:544.
16. Bhutta ZA, Hafeez A, Rizvi A, Ali N, Khan A, Ahmad F, et al. Reproductive,
maternal, newborn, and child health in Pakistan: challenges and opportunities.
Lancet. 2013;381:2207–18.
17. Bhutta ZA, Gazdar H, Haddad L. Seeing the unseen: breaking the logjam of
undernutrition in Pakistan. Ids Bull I Dev Stud. 2013;44:1–9.
18. Bhutta ZA, Gupta I, de’Silva H, Manandhar D, Awasthi S, Hossain SMM. Maternal
and child health: is South Asia ready for change? BMJ. 2004;328:816–9.
19. National Nutrition Survey 2011. Planning Commission, Planning & Development
Division, Government of Pakistan. 2011.
20. Sindh Bureau of Statistics and UNICEF; Sindh Multiple Indicator Cluster Survey
2014, Final Report. Karachi: Sindh Bureau of Statistics and UNICEF; 2015.
21. Gorstein J, Sullivan KM, Parvanta I, Begin F. Indicators and methods for
cross-sectional surveys of vitamin and mineral status of populations. The
Micronutrient Initiative (Ottawa) and the Centers for Disease Control and Submit your next manuscript to BioMed Central
Prevention (Atlanta). 2007. and we will help you at every step:
22. World Health Organization. WHO child growth standards: length/height-for-
age, weight-for-age, weight for- length, weight-for-height and body mass • We accept pre-submission inquiries
index-forage: methods and development. Geneva. 2006. • Our selector tool helps you to find the most relevant journal
23. Gwatkin DR, Rutstein S, Johnson K, Pande R, Wagstaff A. Socio-economic • We provide round the clock customer support
differences in health, nutrition, and population. Washington: World Bank; 2000.
24. Wamani H, Astrom AN, Peterson S, Tumwine JK, Tylleskar T. Boys are more • Convenient online submission
stunted than girls in sub-Saharan Africa: a meta-analysis of 16 demographic • Thorough peer review
and health surveys. BMC Pediatr. 2007;7:17. • Inclusion in PubMed and all major indexing services
25. Novignon J, Aboagye E, Agyemang OS, Aryeetey G. Socioeconomic-related
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