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  • Research article
  • Open Access
  • Open Peer Review

Determinants of stunting and severe stunting among under-fives: evidence from the 2011 Nepal Demographic and Health Survey

  • 1Email author,
  • 2 and
  • 3
BMC Pediatrics201414:239

https://doi.org/10.1186/1471-2431-14-239

  • Received: 1 May 2014
  • Accepted: 22 September 2014
  • Published:
Open Peer Review reports

Abstract

Background

Stunting remains a major public health concern in Nepal as it increases the risk of illness, irreversible body damage and mortality in children. Public health planners can reshape and redesign new interventions to reduce stunting and severe stunting among children aged less than 5 years in this country by examining their determinants. Hence, this study identifies factors associated with stunting and severe stunting among children aged less than five years in Nepal.

Methods

The sample is made up of 2380 children aged 0 to 59 months with complete anthropometric measurements from the 2011 Nepal Demographic and Health Survey (NDHS). Simple and multiple logistic regression analyses were used to examine stunting and severe stunting against a set of variables.

Results

The prevalences of stunting and severe stunting were 26.3% [95% confidence Interval (CI): 22.8, 30.1] and 10.2% (95%CI: 7.9, 13.1) for children aged 0–23 months, respectively, and 40.6 (95%CI: 37.3, 43.2) and 15.9% (95%CI: 13.9, 18.3) for those aged 0–59 months, respectively. After adjusting for potential confounding factors, multivariable analyses showed that the most consistent significant risk factors for stunted and severely stunted children aged 0–23 and 0–59 months were household wealth index (poorest household), perceived size of baby (small babies) and breastfeeding for more than 12 months (adjusted odds ratio (AOR) for stunted children aged 0–23 months = 2.60 [95% CI: (1.87, 4.02)]; AOR for severely stunted children aged 0–23 months = 2.87 [95% CI: (1.54, 5.34)]; AOR for stunted children aged 0–59 months = 3.54 [95% CI: (2.41, 5.19)] and AOR for severely stunted children aged 0–59 months = 4.15 [95% CI: (2.45, 6.93)].

Conclusions

This study suggests that poorest households and prolonged breastfeeding (more than 12 months) led to increased risk of stunting and severe stunting among Nepalese children. However, community-based education intervention are needed to reduce preventable deaths triggered by malnutrition in Nepal and should target children born to mothers of low socioeconomic status.

Keywords

  • Food Insecurity
  • Poor Household
  • Household Food Security
  • Household Food Insecurity
  • Rich Household

Background

Stunting and other effects of under-nutrition increase the risk of illness, irreversible body damage, and increased suboptimal brain development and affect cognitive ability and mortality in children [1]. It is estimated that about 165 million children in many low- and middle-income countries are stunted [2]. Stunting is one of the leading causes of the global burden of disease in childhood and 80% of this burden is in developing countries [3, 4]. Childhood under-nutrition plays an important public health role in monitoring nutritional and health status of the population and survival [5, 6].

Under-nutrition hinders socioeconomic development of a nation [1]. Consequently, its eradication has gained global recognition and sustainable development. In Nepal, stunting remains a serious problem as nearly half (41 per cent) of children aged under five years are stunted [7]. The causes of childhood under-nutrition in Nepal are complex, multidimensional, and interrelated, ranging from fundamental factors such as slow economic growth, to specific factors such as respiratory infection and diarrhoeal diseases [8, 9].

Previous studies in Nepal have found factors such as sex of child, child’s age and birth weight, birth order, number of siblings, wealth index, mother’s education, mother’s body mass index and access to health care to be common determinants of stunting [9, 10]. Additionally, various efforts have been made to reduce under-nutrition in Nepal [11]. Despite these commitments and investment, the prevalence of stunting is still high [7]. In order to reduce the burden of disease on Nepalese children, it is important to target those children who are most at risk, such as stunted children [1214]. This study utilized the most recent Nepal Demographic and Health Survey (NDHS 2011) data to examine the determinants of stunting and severe stunting among children aged less than five years. Findings from this study can be generalised to cover populations with similar characteristics and would be useful to public health researchers and policy makers in reviewing and designing new intervention strategies aimed at reducing the number of malnourished children. The results will also provide vital information on preventable illnesses and identify where health gains can be made to prevent stunting. The findings may also allow policy-makers to direct resources to the most vulnerable segments of the population, and thus make better use of resources.

Ethics

The NDHS surveys were approved by Nepal Health Research Council, Nepal and ICF Macro Institutional Review Board in Calverton, Maryland, USA. The NDHS obtained written consent from the respondents. Mothers provided consent of their children to provide the information. For analysis, Principal Investigator (PI) received permission from Macro International online for the use of available dataset. PI also obtained approval from Social, Behavioural and Educational Research, Institutional Review Board, Tufts University as exempt category 4 as defined in 45 CFR 46.101 (b).

Methods

Data sources

The data examined were from the 2011 NDHS. This survey was conducted by the Department of Health Services, Ministry of Health and Population in collaboration with USAID. The survey data were a two-stage, stratified, nationally representative sample of households. At the first stage of sampling, 289 Primary Sampling Units (PSUs) (95 sub-wards in urban areas and 194 groups of wards in rural areas) were selected using systematic sampling with probability proportion to size.

In the selection of households, 12,918 women were identified as eligible for the individual interview. A total of 12,674 women aged between 15 and 49 years were interviewed. Out of this number, 3,701 were resident in urban areas and 8,973 were rural dwellers. The interviews yielded a response rate of 98%. The 2011 NDHS collected anthropometric data for all children. Non-biological children of women were included in the interviews. Each team of interviewers carried a scale and measuring board. Measurements were made using lightweight SECA scales (with digital screens) on children with valid dates of birth (month and year) and valid measurement of both height and weight. Recumbent heights were measured for children aged 2 years or younger, or those who were shorter than 85 cm. Standing heights were measured for all other children [7]. This present analysis was restricted to children with complete anthropometric measurements, children aged 0–59 months, and the total weighted sample was 2380.

Stunting (Height-for-age)

Height-for-age z-scores were used to assess the chronic nutritional status of children under-5 years. This was accomplished by adapting the Child Growth Standards of the World Health Organization (WHO) [15]. The height-for-age z-score, as defined by the WHO, expresses a child’s height in terms of the number of standard deviations above or below the median height of healthy children in the same age group or in a reference group. We classified children with a measurement of < −2 SD from the median of the reference group as short for their age (stunted), while children with measurement of < −3SD from the median of the reference group were considered to be severely stunted [16].

Potential risk factors

The explanatory variables were classified into four levels: parental-, child-, household- and community-level factors. Parental-level factors included maternal working status, maternal education, mother’s age, mother’s age at child birth, mother’s breastfeeding status, duration of breastfeeding, marital status, mother’s literacy, partner’s education, partner’s occupation, birth order, preceding birth interval, type of delivery assistance, antenatal clinic visits, timing of postnatal check-up and place of delivery. Mode of delivery was divided into three categories: delivered at home, delivered at health facility with non-caesarean section, and delivered at a health facility with caesarean section. Child-level factors were: sex of the baby and acute respiratory infection (defined as having symptoms of cough accompanied by short, rapid breathing which was chest related during 2 weeks preceding the survey). Any child with watery or blood and mucus stool in the preceding 2 weeks was considered as having diarrhoea. Household-level factors were household food insecurity, household wealth index, and sources of drinking water; community-level factors were: type of residence, caste group, ecological zone, geographical zones and sub-region. The household food insecurity factor was calculated by summing all the seven household food insecurity (access) frequency questions withscores ranging from 0 to 27. Food secure was a score of 0, and mild (1–2), moderate (3 to 10), and severe (more than 10) food insecurity represented the three groupings [7]. The caste and ethnic group variables were merged into six categories. This was done by merging all Brahmin Chhetris irrespective of their ecological locations into a single category referred to as “Brahmin/Chhetri”. Similarly, the Janajati from Terai was merged with other Terai castes to make a single category and referred to as “TeraiJanajati and other Terai castes” and Dalits from Hill and Terai were also combined as one. Likewise, Muslims and other castes were put together as “Muslims and others” [7].

Household wealth index was calculated as a score of household assets such as ownership of means of transport, ownership of durable goods, and household facilities. These were weighted using the principal components analysis method [17]. This index was divided into five categories (quintiles), and each household was assigned to one of these categories. The bottom 40% of the households was referred to as the poorest and poorer households, the next 20% as the middle-class households, and the top 40% as rich and richest households.

Statistical analyses

To determine factors associated with stunting and severe stunting in children aged 0–23 months and children 0–59 months – the dependent variable was expressed as a dichotomous variable, i.e. category 0 [not stunted (> − 2SD) or not severely stunted (> − 3SD)] and category 1 [stunted (> − 2SD) or severely stunted (> − 3SD)].

Analyses were performed using Stata version 12.0 (StataCorp, College Station, TX, USA). ‘Svy’ commands were used to allow for adjustments for the cluster sampling design, weights and the calculation of standard errors. The Taylor series linearization method was used in the surveys when estimating confidence intervals (CIs) around prevalence estimates of stunting and severe stunting among children aged 0–59 months. Survey logistic regression was used to adjust for the complex sampling design and weights. First, univariate binary logistic regression analysis was performed to examine the association between stunted and severely stunted children aged 0–23 months and overall stunted children 0–59 months. Second, the factors associated with stunting and severe stunting were examined in a multiple logistic regression model. A stepwise backward elimination approach was applied and collinearity was tested in the final model and reported. The odds ratios with 95% CIs were calculated in order to assess the adjusted risk of independent variables, and those with P < 0.05 were retained in the final model.

Results

Characteristics of the sample

Of the total sample of 2380 children aged 0–59 months, majority (91.1%) lived in rural areas. More than half (56.6%) of the interviewed mothers were employed in the last 12 months, and 32.6% had secondary or higher level of education. Of the total births, 65.5% took place at home and by non-caesarean section, and 30% (see Table 1) were delivered at the health care facility and by non-caesarean section or vaginal birth. The remaining 4.5% were delivered by caesarean section at the health care facility. In the sample, male and female children were almost equally represented. About 83% of mothers had made at least one antenatal clinic visit during pregnancy and a majority of the mothers in the sample were within 20–29 years of age. Also, approximately 44% of households reported food security and 16% reported severe food insecurity. According to the mothers’ perception, 64.5% of children were average size, 17.7% were small or very small size, and 17.8% were large size at birth. As shown in Table 1, the proportion of mothers who could not read a sentence was 42.7%. Nearly 24% of children lived in the Eastern geographical zones and 31.6%, 18.2%, 15.1% and 11.3% of children lived in Central, Western, Mid-western, and Far-western geographical zones respectively.As shown in Figure 1, the prevalence of stunted children aged 0–23 months was 26% and a higher 41% for children aged 0–59 months. The overall prevalence of severely stunted children aged 0–23 months and 0–59 months were 10% and 16%, respectively.
Table 1

Characteristics of parental-, child-, household- and community-level factors of stunted children aged 0–59 months in Nepal 2011

Characteristic

n

%

Parental factors

  

Maternal working status

  

Non-working

1033

43.4

Working (past 12 months)

1347

56.6

Maternal education

  

No education

1128

47.4

Primary

469

19.7

Secondary and above

782

32.9

Partner’s occupation

  

Non agriculture

1679

70.6

Agriculture

593

24.9

Not working

108

4.5

Partner’s education

  

No education

530

22.4

Primary

578

24.4

Secondary and above

1262

53.3

Mother’s age

  

15-24 years

997

41.9

25-34 years

1103

46.3

35-49years

281

11.8

Mother’s age at birth

  

< 20 years

492

20.7

20-29 years

1458

61.3

30-39 years

367

15.4

≥40 years

62

2.6

Marital status

  

Currently married

2361

99.2

Formerly married^

19

0.8

Birth order

  

First-born

835

35.1

2nd -4th

1235

51.9

5 or more

310

13.0

Preceding birth interval

  

No previous birth

835

35.1

< 24 months

324

13.6

> 24 months

1219

51.3

Place of delivery

  

Home

1560

65.6

Health facility

820

34.4

Mode of delivery

  

Non-caesarean

2273

95.5

Caesarean

107

4.5

Combined Place and mode of delivery

  

Home delivery

1560

65.5

Health facility with non-caesarean

713

30.0

Health facility with caesarean

107

4.5

Type of delivery assistance

  

Health professional

772

32.4

Traditional birth attendant

44

1.9

Relatives and other untrained personnel

1490

62.6

No one

74

3.1

Antenatal clinic visits

  

None

317

16.8

1-3.

647

34.3

4+

921

48.9

Timing of postnatal check-up

  

No postnatal check-up

1756

73.8

0-2 days

429

18.0

Delayed

196

8.2

Currently breastfeeding

  

Yes

1830

76.9

No

550

23.1

Duration of breastfeeding

  

Up to 12 months

498

20.9

> 12 months

1882

79.1

Mother’s literacy

  

Can’t read at all

1016

42.7

Can read

1364

57.3

Child level factors

  

Sex of baby

  

Male

1208

50.7

Female

1172

49.3

Perceived size of baby at birth

  

Small

421

17.7

Average

1531

64.5

Large

424

17.8

Child’s age in months

  

0-5

206

8.8

6-11

240

10.3

12-17

269

11.6

18-23

215

9.2

24-29

227

9.8

30-35

252

10.8

36-41

273

11.7

42-47

230

9.9

48-53

220

9.5

54-59

195

8.4

Child had diarrhoea recently

  

No

2028

85.2

Yes

352

14.8

Child had fever in last two weeks

  

No

1883

79.1

Yes

497

20.9

Household level factors

  

Household food insecurity (Access)

  

Food secure

1004

43.6

Mildly insecure

129

5.6

Moderately

803

34.9

Severely

365

15.9

Wealth index

  

Poorest

608

25.6

Poorer

483

20.3

Middle

555

23.3

Rich

406

17.1

Richest

328

13.8

Source of drinking water

  

Unprotected

409

17.2

Protected

1972

82.8

Community level factors

  

Type of residence

  

Urban

211

8.9

Rural

2169

91.1

Caste group

  

B/C (Hill and Terai)

724

30.4

Newar

63

2.7

Hill Janajati

541

22.8

TeraiJanajati and other Terai castes

469

19.7

Dalit

434

18.2

Muslim and others

149

6.3

Ecological Zone

  

Mountain

189

7.9

Hill

940

39.5

Terai

1252

52.6

Geographic Zones

  

Eastern

567

23.8

Central

751

31.6

Western

434

18.2

Mid-western

359

15.1

Far-western

269

11.3

Sub-Region

  

Eastern Mountain

46

1.9

Central Mountain

42

1.7

Western Mountain

101

4.3

Eastern Hill

174

7.3

Central Hill

215

9.0

Western Hill

274

11.5

Mid-Western Hill

165

6.9

Far-Western Hill

112

4.7

Eastern Terai

348

14.6

Central Terai

495

20.8

Western Terai

160

6.7

Mid-Western Terai

136

5.7

Far-Western Terai

113

4.7

^divorced/separated/widowed.

Household food insecurity scores: Food secure (score, 0); mildly insecurity (score, 1–2), moderately (score, 3–10) and severely (score, 10–27).

Figure 1
Figure 1

Prevalence of stunting and severe stunting among children aged 0-59 months.

Multivariate analyses

Tables 2 and 3 show the unadjusted and adjusted ORs for the association between stunted and severely stunted children by parental-, child-, household- and community-level characteristics of children aged 0–23 and aged 0–59 months.
Table 2

Unadjusted and adjusted odds ratios (OR) (95% CI) for stunted children aged 0–23 and 0–59 months

Characteristic

Stunted children 0–23 Months

Stunted children 0–59 Months

 

Unadjusted Odd Ratio (OR) [95%CI]

P

Adjusted Odd Ratio (AOR) [95%CI]

P

Unadjusted Odd Ratio (OR) [95%CI]

P

Adjusted Odd Ratio (AOR) [95%CI]

P

Parental factors

        

Maternal working status

        

Non-working

1.00

   

1.00

   

Working (past 12 months)

1.60 (1.09, 2.34)

0.015

  

1.30 (0.99, 1.70)

0.057

  

Maternal education

        

No education

1.00

   

1.00

   

Primary

0.75 (0.47,1.18)

0.205

  

0.77 (0.58, 1.03)

0.079

  

Secondary and above

0.39 (0.24, 0.62)

<0.001

  

0.46 (0.35, 0.60)

<0.001

  

Partner’s occupation

        

Non agriculture

1.00

   

1.00

   

Agriculture

1.80 (1.24,2.63)

0.002

  

1.68 (1.30, 2.18)

<0.001

  

Not working

0.28 (0.07,0.62)

0.071

  

0.57 (0.29, 1.13)

0.109

  

Partner’s education

        

No education

1.00

   

1.00

   

Primary

0.67 (0.40, 1.11)

0.121

  

0.91 (0.62, 1.33)

0.620

  

Secondary and above

0.40 (0.26, 0.60)

<0.001

  

0.58 (0.42, 0.79)

0.001

  

Mother’s age

        

15-24 years

1.00

   

1.00

   

25-34 years

1.16 (0.81,1.67)

0.420

  

1.16 (0.94,1.43)

0.159

  

35-49years

3.14 (1.54, 6.01)

0.001

  

1.91 (1.39, 2.63)

<0.001

  

Mother’s age at birth

        

< 20 years

1.00

 

1.00

 

1.00

   

20-29 years

0.98 (0.60,1.62)

0.944

1.02 (0.58, 1.80)

0.955

0.91 (0.68, 1.21)

0.508

  

30-39 years

1.17 (0.65,2.11)

0.595

0.95 (0.48, 1.87)

0.877

1.06 (0.75, 1.52)

0.728

  

40 and above

11.06 (4.26, 28.72)

<0.001

7.31 (2.12, 25.22)

0.002

2.28 (1.27, 4.11)

0.006

  

Marital status

        

Currently married

1.00

   

1.00

   

Formerly married^

3.10 (0.26, 36.98)

0.370

  

1.52 (0.51, 4.52)

0.450

  

Birth order

        

First-born

1.00

   

1.00

   

2nd -4th

1.60 (1.13, 2.25)

0.008

  

1.25 (1.00, 1.56)

0.052

  

5 or more

3.45 (1.91, 6.23)

<0.001

  

2.15 (1.57, 2.94)

<0.001

  

Preceding birth interval

        

No previous birth

1.00

   

1.00

   

< 24 months

2.20 (1.35, 3.58)

0.002

  

1.64 (1.22, 2.20)

0.001

  

> 24 months

1.77 (1.22, 2.57)

0.003

  

1.34 (1.08, 1.66)

0.009

  

Type of delivery assistance

        

Health professional

1.00

   

1.00

   

Traditional birth attendant

0.88 (0.19, 4.04)

0.873

  

1.24 (0.58, 2.64)

0.578

  

Relatives or other

3.14 (2.00, 4.94)

<0.001

  

2.39 (1.87, 3.06)

<0.001

  

No one

5.10 (2.16, 12.04)

<0.001

  

5.63 (3.39, 9.32)

<0.001

  

Combined Place and mode of delivery

        

Home delivery

1.00

 

1.00

 

1.00

 

1.00

 

Health facility with non-caesarean

0.33 (0.21,0.51)

<0.001

0.54 (0.33, 0.90)

0.018

0.42 (0.33, 0.52)

<0.001

0.65 (0.51, 0.84)

0.001

Health facility with caesarean

0.22 (0.07, 0.66)

0.007

0.53 (0.16, 1.75)

0.298

0.28 (0.16, 0.50)

<0.001

0.53 (0.29, 0.95)

0.033

Timing of postnatal check-up

        

No postnatal check-up

1.00

   

1.00

   

0-2 days

0.39 (0.24, 0.63)

<0.001

  

0.38 (0.30, 0.49)

<0.001

  

Delayed

0.45 (0.23, 0.87)

0.019

  

0.40 (0.26, 0.60)

<0.001

  

Antenatal clinic visits

        

None

1.00

   

1.00

   

1-3.

0.71 (0.36, 1.39)

0.312

  

0.69 (0.47, 1.01)

0.056

  

4+

0.41 (0.23, 0.73)

0.003

  

0.46 (0.32,0.65)

<0.001

  

Currently breastfeeding

        

Yes

1.00

   

1.00

 

1.00

 

No

1.02 (0.33, 3.18)

0.971

  

0.97 (0.75, 1.26)

0.841

0.70 (0.53, 0.94)

0.017

Duration of breastfeeding

        

Upto 12 months

1.00

 

1.00

 

1.00

 

1.00

 

> 12 months

2.80 (1.91, 4.09)

<0.001

2.60 (1.87, 4.02)

<0.001

4.22 (3.12, 5.69)

<0.001

3.54 (2.41, 5.19)

<0.001

Mother’s literacy

        

Can’t read at all

1.00

   

1.00

   

Can read

0.52 (0.35, 0.76)

0.001

  

0.58 (0.45, 0.73)

<0.001

  

Child level factors

        

Child age

        

Sex of baby

        

Male

1.00

   

1.00

   

Female

0.75 (0.53, 1.06)

0.104

  

0.93 (0.78, 1.10)

0.392

  

Perceived size of baby at birth

        

Small

1.00

 

1.00

 

1.00

 

1.00

 

Average

0.51 (0.32, 0.84)

0.008

0.61 (0.36, 1.04)

0.070

0.64 (0.49, 0.83)

0.001

0.68 (0.51, 0.90)

0.008

Large

0.40 (0.22, 0.75)

0.004

0.42 (0.36, 0.83)

0.013

0.46 (0.33, 0.65)

<0.001

0.47 (0.33, 0.67)

<0.001

Child’s age in months

2.39 (1.59, 3.59)

<0.001

  

1.34 (1.25, 1.44)

<0.001

1.11 (1.01, 1.23)

0.031

Child had diarrhoea recently

        

No

1.00

   

1.00

   

Yes

1.29 (0.83, 2.02)

0.254

  

0.91 (0.66, 1.27)

0.589

  

Child had fever in last two weeks

        

No

1.00

   

1.00

   

Yes

1.20 (0.79,1.84)

0.389

  

0.79 (0.63, 0.98)

0.035

  

Household level factors

        

Food insecurity (Access)

        

Food secure

1.00

   

1.00

   

Mildly insecurity

0.79 (0.34, 1.82)

0.571

  

1.11 (0.71, 1.76)

0.638

  

Moderately

2.34 (1.48, 3.70)

<0.001

  

1.66 (1.28, 2.16)

<0.001

  

Severely

2.94 (1.54, 5.63)

0.001

  

2.22 (1.54, 3.20)

<0.001

  

Wealth index

        

poorest

1.00

 

1.00

 

1.00

 

1.00

 

poorer

0.79 (0.50, 1.25)

0.314

0.93 (0.58, 1.50)

0.711

0.65 (0.47, 0.88)

0.005

0.67 (0.48, 0.94)

0.020

middle

0.45 (0.28, 0.72)

0.001

0.59 (0.36, 0.97)

0.039

0.42 (0.30, 0.59)

<0.001

0.47 (0.33, 0.68)

<0.001

richer

0.25 (0.14, 0.45)

<0.001

0.31 (0.16, 0.59)

<0.001

0.33 (0.24, 0.46)

<0.001

0.38 (0.25, 0.56)

<0.001

richest

0.16 (0.07, 0.34)

<0.001

0.29 (0.12, 0.67)

0.004

0.26 (0.18, 0.37)

<0.001

0.37 (0.25, 0.55)

<0.001

Source of drinking water

        

Unprotected

1.00

 

1.00

 

1.00

   

Protected

1.50 (0.95, 2.36)

0.084

  

1.08 (0.81, 1.43)

0.609

  

Community level factors

        

Type of residence

        

Urban

1.00

   

1.00

   

Rural

2.14 (1.26, 3.64)

0.005

  

1.95 (1.47, 2.58)

<0.001

  

Caste group

        

B/C (Hill and Terai)

1.00

   

1.00

   

Newar

0.72 (0.26, 2.05)

0.542

  

0.77 (0.40, 1.48)

0.423

  

Hill Janajati

1.14 (0.71, 1.85)

0.577

  

1.35 (0.98, 1.84)

0.063

  

TeraiJanajati and other terai castes

1.52 (0.94, 2.43)

0.086

  

1.11 (0.77, 1.62)

0.566

  

Dalit

1.46 (0.92, 2.33)

0.110

  

1.53 (1.18, 1.99)

0.002

  

Muslim and others

0.91 (0.36, 2.26)

0.832

  

0.80 (0.48, 1.32)

0.382

  

Ecological Zone

        

Mountain

1.00

   

1.00

 

1.00

 

Hill

0.55 (0.35, 0.87)

0.010

  

0.63 (0.47, 0.84)

0.002

0.68 (0.50, 0.93)

0.015

Terai

0.48 (0.30, 0.77)

0.002

  

0.52 (0.39, 0.70)

<0.001

0.80 (0.57, 1.12)

0.193

Geographic Zones

        

Eastern

1.00

   

1.00

   

Central

1.28 (0.75, 2.17)

0.366

  

1.04 (0.72, 1.49)

0.832

  

Western

1.13 (0.61, 2.10)

0.692

  

1.07 (0.72, 1.60)

0.738

  

Mid-western

1.64 (0.96, 2.77)

0.068

  

1.71 (1.15, 2.55)

0.008

  

Far-western

1.28 (0.73, 2.25)

0.387

  

1.47 (0.96, 2.24)

0.075

  

^divorced/separated/widowed.

Household food insecurity scores: Food secure (score, 0); mildly insecurity (score, 1–2), moderately (score, 3–10) and severely (score, 10–27).

Table 3

Unadjusted and adjusted odds ratios (OR) (95% CI) for severely stunted children aged 0–23 and 0–59 months

Characteristic

Severely stunted children 0–23 Months

Severely stunted children 0–59 Months

 

Unadjusted OR [95%CI]

P

Adjusted Odd Ratio (AOR) [95%CI]

P

Unadjusted OR [95%CI]

P

Adjusted Odd Ratio (AOR) [95%CI]

P

Parental factor

        

Maternal working status

        

Non-working

1.00

   

1.00

   

Working (past 12 months)

2.10 (1.16, 3.80)

0.015

  

1.10 (0.78, 1.55)

0.603

  

Maternal education

        

No education

1.00

   

1.00

   

Primary

0.69 (0.34, 1.42)

0.313

  

0.56 (0.37, 0.84)

0.005

  

Secondary and above

0.44 (0.21, 0.91)

0.027

  

0.35 (0.24, 0.52)

<0.001

  

Partner’s occupation

        

Non agriculture

1.00

   

1.00

   

Agriculture

1.39 (0.77, 2.52)

0.270

  

1.75 (1.20, 2.54)

0.004

  

Not working

0.59 (0.10, 3.54)

0.558

  

0.40 (0.14, 1.15)

0.088

  

Partner’s education

    

1.00

   

No education

1.00

   

0.73 (0.46, 1.15)

0.172

  

Primary

0.62 (0.26, 1.47)

0.277

  

0.43 (0.28, 0.65)

<0.001

  

Secondary and above

0.39 (0.19, 0.78)

0.008

      

Mother’s age

        

15-24 years

1.00

   

1.00

   

25-34 years

1.29 (0.71,2.33)

0.406

  

1.07 (0.77, 1.49)

0.684

  

35-49years

4.50 (2.04, 9.94)

<0.001

  

1.84 (1.28, 2.65)

0.001

  

Mother’s age at birth

        

< 20 years

1.00

   

1.00

   

20-29 years

0.72 (0.36, 1.44)

0.351

  

0.79 (0.55, 1.14)

0.213

  

30-39 years

1.36 (0.60, 3.10)

0.457

  

1.17 (0.76, 1.79)

0.481

  

40 and above

5.85 (1.81, 18.96)

0.003

  

1.53 (0.76, 3.08)

0.232

  

Marital status

        

Currently married

-'

-'

  

1.00

   

Formerly married^

-'

-'

  

0.76 (0.23, 2.54)

0.653

  

Birth order

        

First-born

1.00

   

1.00

   

2nd -4th

2.08 (1.14, 3.79)

0.017

  

1.39 (1.01, 1.90)

0.042

  

5 or more

4.68 (2.19, 10.00)

<0.001

  

2.14 (1.39, 3.30)

0.001

  

Preceding birth interval

        

No previous birth

1.00

 

1.00

 

1.00

   

< 24 months

3.59 (1.75, 7.38)

0.001

2.38 (1.12, 5.03)

0.024

2.25 (1.51, 3.34)

<0.001

  

> 24 months

2.21 (1.18, 4.14)

0.014

1.54 (0.80, 2.99)

0.195

1.36 ( 0.97, 1.89)

0.073

  

Type of delivery assistance

        

Health professional

1.00

 

1.00

 

1.00

 

1.00

 

Traditional birth attendant

1.56 (0.20, 12.33)

0.674

1.58 (0.19, 13.14)

0.670

1.08 (0.24, 4.82)

0.922

0.65 (0.14, 3.11)

0.589

Relatives or other

3.67 (1.91, 7.03)

<0.001

2.15 (0.98, 4.72)

0.056

2.65 (1.83, 3.83)

<0.001

1.55 (1.05, 2.31)

0.029

No one

7.32 (2.53, 21.22)

<0.001

3.69 (1.14, 11.93)

0.029

7.07 (3.84, 13.01)

<0.001

2.88 (1.47, 5.67)

0.002

Combined Place and mode of delivery

       

Home delivery

1.00

   

1.00

   

Health facility with non-caesarean

0.33 (0.18,0.60)

<0.001

  

0.41 (0.29, 0.58)

<0.001

  

Health facility with caesarean

0.37 (0.07,1.90)

0.231

  

0.16 (0.04, 0.59)

0.006

  

Timing of postnatal check-up

        

No postnatal check-up

1.00

   

1.00

   

0-2 days

0.44 (0.23,0.85)

0.014

  

0.34 (0.23, 0.51)

<0.001

  

Delayed

0.33 (0.11, 0.97)

0.045

  

0.29 (0.14, 0.62)

0.001

  

Antenatal clinic visits

        

None

1.00

   

1.00

   

1-3.

0.72 (0.34,1.49)

0.372

  

0.77 (0.52, 1.15)

0.201

  

4+

0.50 (0.25,1.01)

0.053

  

0.46 (0.30, 0.71)

0.001

  

Currently breastfeeding

        

Yes

1.00

   

1.00

 

1.00

 

No

0.86 (0.27, 2.70)

0.789

  

0.58 (0.41, 0.82)

0.002

0.49 (0.34, 0.69)

<0.001

Duration of breastfeeding

        

Up to 12 months

1.00

 

1.00

 

1.00

 

1.00

 

> 12 months

2.90 (1.81, 5.22)

<0.001

2.87 (1.54, 5.34)

0.001

3.75 (2.30, 6.11)

<0.001

4.15 (2.49, 6.93)

<0.001

Mother’s literacy

        

Can’t read at all

1.00

   

1.00

 

1.00

 

Can read

0.55 (0.31, 0.97)

0.039

  

0.42 (0.31, 0.59)

<0.001

0.61 (0.43, 0.86)

0.005

Child level factors

        

Sex of baby

        

Male

1.00

 

1.00

 

1.00

   

Female

0.46 (0.29, 0.72)

0.001

0.44 (0.28, 0.71)

0.001

0.95 (0.72, 1.26)

0.710

  

Perceived size of baby at birth

        

Small

1.00

   

1.00

 

1.00

 

Average

0.65 (0.37, 1.14)

0.133

  

0.70 (0.50, 0.98)

0.038

0.81 (0.57, 1.16)

0.243

Large

0.46 (0.20, 1.07)

0.070

  

0.43 (0.27, 0.68)

<0.001

0.47 (0.29, 0.74)

0.001

Child’s age in months

2.62 (1.41, 4.86)

0.002

  

1.23 (1.14, 1.33)

<0.001

  

Child had diarrhoea recently

        

No

1.00

   

1.00

   

Yes

1.53 (0.80,2.93)

0.201

  

1.01 (0.69, 1.47)

0.968

  

Child had fever in last two weeks

       

No

1.00

   

1.00

   

Yes

1.50 (0.85, 2.65)

0.165

  

0.89 (0.64, 1.23)

0.478

  

Household level factors

        

Household Food Insecurity (Access)

       

Food secure

1.00

   

1.00

   

Mildly insecurity

1.77 (0.50, 6.34)

0.377

  

0.85 (0.43, 1.68)

0.637

  

Moderately

2.88 (1.27,6.55)

0.012

  

1.61 (1.06, 2.43)

0.024

  

Severely

4.80 (2.00, 11.50)

<0.001

  

2.41 (1.47, 3.96)

0.001

  

Wealth Index

        

poorest

1.00

 

1.00

 

1.00

 

1.00

 

poorer

0.82 (0.42, 1.60)

0.558

0.81 (0.40, 1.66)

0.566

0.76 (0.52, 1.11)

0.156

0.91 (0.61, 1.36)

0.638

middle

0.42 (0.20, 0.87)

0.020

0.49 (0.22, 1.05)

0.067

0.45 (0.30, 0.69)

<0.001

0.60 (0.40, 0.91)

0.016

richer

0.28 (0.11, 0.69)

0.006

0.36 (0.14, 0.93)

0.034

0.33 (0.20, 0.53)

<0.001

0.49 (0.30, 0.82)

0.007

richest

0.19 (0.06, 0.60)

0.005

0.33 (0.10, 1.15)

0.081

0.19 (0.11, 0.33)

<0.001

0.40 (0.20, 0.80)

0.009

Source of drinking water

        

Unprotected

1.00

   

1.00

   

Protected

0.91 (0.48,1.74)

0.779

  

0.87 (0.52, 1.24)

0.455

  

Community level factors

        

Type of residence

        

Urban

1.00

   

1.00

   

Rural

1.62 (0.79, 3.30)

0.187

  

3.00 (1.86, 4.83)

<0.001

  

Caste group

        

B/C (Hill and Terai)

1.00

   

1.00

   

Newar

0.84 90.22,3.25)

0.796

  

0.82 (0.31, 2.13)

0.682

  

Hill Janajati

0.97 (0.45, 2.09)

0.935

  

1.25 (0.87, 1.80)

0.233

  

TeraiJanajati and other terai castes

0.99 (0.38, 2.64)

0.997

  

1.30 (0.72, 2.38)

0.385

  

Dalit

1.35 (0.68, 2.69)

0.389

  

1.74 (1.24, 2.44)

0.001

  

Muslim and others

0.69 (0.26, 1.87)

0.468

  

0.92 (0.46, 1.85)

0.825

  

Ecological Zone

        

Mountain

1.00

   

1.00

   

Hill

0.81 (0.39, 1.68)

0.565

  

0.69 (0.47, 1.01)

0.059

  

Terai

0.60 (0.28, 1.29)

0.191

  

0.63 (0.42, 0.94)

0.025

  

Geographic Zones

        

Eastern

1.00

   

1.00

   

Central

1.46 (0.64, 3.30)

0.363

  

1.37 (0.86, 2.20)

0.184

  

Western

2.13 (0.91, 5.03)

0.083

  

1.23 (0.72, 2.09)

0.449

  

Mid-western

2.41 (1.16, 5.00)

0.018

  

1.77 (1.12, 2.81)

0.015

  

Far-western

1.70 (0.68, 4.25)

0.254

  

1.46 (0.85, 2.52)

0.168

  

^divorced/separated/widowed.

Household food insecurity scores: Food secure (score, 0); mildly insecurity (score, 1–2), moderately (score, 3–10) and severely (score, 10–27).

Risk factors for stunting

As shown in Table 2, children aged 0–23 months delivered by older mothers (adjusted OR = 7.36, 95%CI: 2.11, 25.75; p = 0.002 for mothers aged 40 and above) were significantly more likely to be stunted than those delivered by younger mothers (mothers less than 20 years old).

For children aged 0–23 months, those who were delivered at the health facility by non-caesarean section (adjusted OR = 0.55, 95%CI: 0.33, 0.92; p = 0.022) were significantly less likely to be stunted compared with children delivered at home. Babies who were perceived to be large by their mothers were 58% less likely to be stunted than those who were perceived to be small (adjusted OR = 0.42, 95%CI: 0.22, 0.81; p = 0.010 for large babies). Also, children aged 0–23 months who were breastfed for up to 12 months were significantly less likely to be stunted than those breastfed for more than 12 months.

Children aged 0–23 months from middle-income households (adjusted OR = 0.53, 95%CI: 0.33, 0.85; p = 0.009), those from richer households (adjusted OR = 0.28, 95%CI: 0.15, 0.53; p < 0.001) and those from richest households (adjusted OR = 0.26, 95%CI: 0.11, 0.60; p = 0.002) were significantly less likely to be stunted compared to those from poorest households. Children aged 0–23 months who had no access to protected drinking water were 1.74 times more likely to be stunted than those who had access to protected drinking water. In the final model, we removed household wealth index and replaced with father’s education. The result indicated that children aged 0–23 months whose fathers attained secondary education or higher were 44% less likely to be stunted compared with children whose fathers had no formal education (adjusted OR = 0.56; CI: 0.37, 0.86; p = 0.007 for fathers with secondary education or higher).

Children aged 0–59 months who were currently being breastfed were significantly less likely to be severely stunted compared with children of the same age group who were not currently being breastfed (adjusted OR = 0.70; CI: 0.54, 0.94; p = 0.017); and children aged 0–59 months who breastfed for more than 12 months were more likely to be stunted than those breastfed for up to 12 months. Children aged 0–59 months who were perceived by their mothers to be average size (adjusted OR = 0.68, 95%CI: 0.51, 0.90; p = 0.008) and those perceived to be large (adjusted OR = 0.47, 95%CI: 0.33, 0.67; p < 0.001) at the time of delivery were significantly less likely to be stunted than children of the same age perceived to be small at the time of delivery.

Children aged 0–59 months from poorer households (adjusted OR = 0.67, 95%CI: 0.48, 0.94; p = 0.020), middle-income households (adjusted OR = 0.47, 95%CI: 0.33, 0.68; p < 0.001), and richer households (adjusted OR = 0.38, 95%CI: 0.25, 0.56; p < 0.001) and those from richest households (adjusted OR = 0.37, 95%CI: 0.25, 0.55; p < 0.001) were significantly less likely to be stunted compared with those from poorest households. Increasing age of the child was significantly associated with stunting (adjusted OR = 1.11, 95%CI: 1.01, 1.23; p = 0.031) andchildren aged 0–59 months from the Hill zone (adjusted OR = 0.68, 95%CI: 0.50, 0.93; p = 0.015) were significantly less likely to be stunted compared with those who lived in the Mountains. In the final model for stunted children aged 0–59 months, we removed household wealth index and replaced it with household food security and our result revealed that households who reported moderate and severe food insecurity were 1.37 times and 1.67 times more likely to be stunted than those who reported food security (adjusted OR = 1.37, 95%CI: 1.02, 1.85; p = 0.039 for moderately food insecure households and adjusted OR = 1.67, 95%CI: 1.17, 2.38; p = 0.005) for severely food insecure households).

Risk factors for severe stunting

Table 3 illustrates the unadjusted and adjusted odds ratios for the association between severely stunted children and parental-, child-, household- and community-level factors of children aged 0–23 months and 0–59 months. Girls aged 0–23 months had statistically significantly reduced odds of being severely stunted compared to boys aged 0–23 months (AOR = 0.44, 95% CI: 0.28, 0.71; p = 0.001). Children aged 0–23 months from rich household had reduced odds of being severely stunted (AOR = 0.36, 95%CI: 0.14, 0.93; p = 0.034) compared with those from poorest household. Children aged 0–23 months who were delivered without assistance to their mothers and mothers of children with preceding birth interval less than 24 months were significantly more likely to be severely stunted than those children delivered by health professional and those with mothers with no previous birth. In the final model for severely stunted children aged 0–23 months, when household wealth index was removed and replaced with household food security, the result indicated that household who reported severe food insecurity were 3.27 times more likely to be severely stunted than those who reported food security (adjusted OR = 3.27, 95%CI: 1.30, 8.20; p = 0.016).

Children aged 0–59 months who were delivered with assistance by relatives or others and those delivered with no assistance were significantly more likely to be stunted compared with children who were delivered with assistance from a health professional. The odds for severely stunted children aged 0–59 months for babies not currently being breastfed and children whose mothers could not read decreased significantly by 41% (adjusted OR = 0.49; CI: 0.34, 0.69; p < 0.001 for currently being breastfed children aged 0–59 months) and 51% (adjusted OR = 0.49; CI: 0.34, 0.69; p < 0.001 for children whose mothers could read). Children aged 0–59 months who were breastfed for more than 12 months (adjusted OR = 4.15, 95%CI: 2.49, 6.93; p < 0.001) were significantly more likely to be severely stunted than those children aged 0–59 months who were breastfed for up to 12 months.

Children aged 0–59 months perceived by their mothers to be large (adjusted OR = 0.47, 95%CI: 0.33, 0.67; p = 0.001) were significantly less likely to be stunted than children of the same group perceived to be small by their mothers at the time of delivery. Children aged 0–59 months from middle-income households (adjusted OR = 0.60, 95%CI: 0.40, 0.91; p = 0.016), richer households (adjusted OR = 0.49, 95%CI: 0.30, 0.82; p = 0.007) and those from richest households (adjusted OR = 0.40, 95%CI: 0.20, 0.80; p = 0.009) were significantly less likely to be severely stunted than those children aged 0–59 months from poorest households. In the final model for severely stunted children aged 0–59 months, when household wealth index was removed and replaced with type of residence, we observed that children aged 0–59 months who lived in rural areas were more likely to be severely stunted than their urban counterparts (adjusted OR = 1.99, 95%CI: 1.23, 3.25; p = 0.006 for rural residence).

Discussion

This paper presents the risk factors for stunting and severe stunting among children aged 0–23 and 0–59 months using the 2011 NDHS data. The findings from this study would enable public health researchers to reshape and redesign new educational interventions to reduce the prevalence of stunting in Nepal. The prevalences of stunting and severe stunting in children less than 23 months of age were as high as the global estimate of 27% [18] while the prevalences of stunting and severe stunting in children aged 0–59 months were also high (NDHS, 2011) but slightly lower than those of Bangladesh and India [19, 20]. Despite many interventions to reduce the level of stunting among under-five children in Nepal, over the past 10 years, the prevalence remains consistently high [8]. This explains the fact that there are other underlying factors contributing to the high rate of stunting among children aged less than five years. However, the reported prevalence of stunting and severe stunting among children aged under five years in Nepal was within the highest range (40-58%) reported among other 20 developing countries [21].

This study indicated that increasing age of the child was significantly associated with stunting and severe stunting and children aged 0–23 months significantly reported a lower risk of stunting and severe stunting than those in the older age group of 0–59 months. Similar results were found by other researchers [22, 23]. The finding could be explained by the protective effect of breastfeeding as most children in Nepal are breastfed even into the second year of life [24]. The high rate of stunting and severe stunting observed among children 0–59 months may be associated with inappropriate food supplementation during the weaning period [24, 25].

This study revealed that breastfed children for more than 12 months were significantly more likely to be stunted and severely stunted than those breastfed for up to 12 months, which indicated that stunting and severe stunting correlated with prolonged duration of breastfeeding. These findings support the study that stunting occurs most readily in the first 6–18 months [26]. Another study [27] found that stunting was most common among children aged 36–47 months (51.89%) followed by 12–23 age groups (50.64%) and it was lowest in the older age group of 48–59 months (39.13%). These variations could be linked to other contributing factors such as culture, exclusive breastfeeding status, time of initiation of complementary feeding, socioeconomic dynamics and parents’ educational status in that community [24, 25].

Another risk factor for stunting and severe stunting in this age group was household wealth index. Our study revealed that children from poorest households were more likely to become stunted or severely stunted compared to those from middle-income, richer and richest households. This finding suggests that a child’s health status depends upon the socio-economic standing of their household. Also, educated mothers who are more conscious about their children’s health and nutritional needs are most likely to come from richer households. Previous studies among Peruvian, Cambodian and Bangladeshi children found household wealth index to be a key predictor for stunting and severe stunting among children under five years of age [25, 2830]. The association between low income and stunting has been observed in several other studies [25, 29, 3133]. Rich households have greater purchasing power for food and other consumer goods needed to ensure the health of children. Such children are therefore not likely to be exposed to conditions that would lead to stunting or severe stunting.

Our study also revealed that children perceived by their mothers to be small had a higher risk of being stunted compared to those perceived to be average or large. These findings were supported by studies previously conducted in Pakistan and Mexico [34, 35] which indicated that children less than 24 months of age with lower birth weight were 3 times more likely to be stunted than children of the same age group with normal or higher birth weight. As the incidence of low birth weight (<2.5 kg) is high (21%) in Nepal [21], prevention of intrauterine growth retardation, premature delivery and maternal malnutrition should be one of the basis in public health level intervention strategy for infant stunting. The assessment of the baby’s size at birth by health-care providers could be significant in identifying children at risk of stunting. In our analysis, maternal age at child’s birth was found to be an important risk factor for childhood stunting and severe stunting. Children in the age group 0–23 months born to younger mothers (aged <20 years) were less likely to be stunted compared with those born to older mothers (aged >20 years). These results were consistent with a study conducted in Iran [36]. However, in the Iran study, it was found that children born to mothers older than 35 years of age were more likely to be stunted and severely stunted. On the contrary, a study in Mexico [35] found that maternal age at child’s birth was not a predictor for stunting. These discrepancies in findings could be attributed to differences in cultures, socioeconomic dynamics and nutritional factors among the various communities, as the studies were conducted in different continents of the world.

Among children aged 0–59 months, the type of delivery assistance received was found to be a significant risk factor for stunting. Children who were delivered with assistance from traditional birth attendants or relatives and those who were delivered without any assistance were significantly more likely to be stunted compared to those who were delivered with assistance from health professionals. This finding is supported by a study conducted in India [37] in which children delivered at home were more likely to be stunted compared to those delivered at a health facility. In another study conducted in Bangladesh [33], it was reported that the place of delivery and the assistance received were significantly associated with stunting and severe stunting among pre-school children. These findings could be explained by the health information given to mothers by health professionals during antenatal and postpartum periods. Possible health information that health professionals could offer to mothers may include information on exclusive breastfeeding, initiation of complementary feeding as well as comprehensive care for the new-borns. Further analysis revealed that 78% of mothers who go for institutional delivery are those from richest wealth quintiles compared with 22% of mothers from richest wealth quintiles who delivered their babies at home.

Our study also found that breastfed children were significantly less likely to be stunted compared to non-breastfed children. Also, children born to mothers who could read were significantly less likely to be stunted compared to those born to mothers who could not read at all. This reflects the importance of mother education and breastfeeding in the development of healthy children and has been reported in previous studies [30, 31, 33]. We also found that children who were breastfed and born to educated mothers were less likely to be stunted compared to those who were not breastfed and born to uneducated mothers.

In addition, our study showed that children resident in the Hill zone were significantly less likely to be severely stunted compared to those from the Mountains. This finding is consistent with studies conducted in Bangladesh [32, 33] in which the region where a child was born played a significant role in predicting stunting. This association could be due to the nature of dietary intake, access to food and cultural diversity in that environment.

Replacing household wealth with household food insecurity and type of residence in the final model, this study found a strong association between household food insecurity and stunting and severe stunting among children aged 0–59 months and 0–23 months, respectively. These findings were consistent with a study carried out in Colombia [38] which indicated that household food insecurity was significantly associated with stunting among pre-school children. Our study also found that children aged 0–59 months who lived in the rural areas were significantly more likely to be stunted compared to their urban counterparts. A two-stage cluster study carried out in Vietnam [23] found that living in rural areas was a risk factor for malnutrition including stunting. This study also revealed that rich families were more likely to report food security and also more likely to reside in urban areas.

As the rate of stunting and severe stunting are still high in Nepal, program intervention strategies targeting long-term prevention of stunting in this country are needed to effectively and sustainably improve their prevalence. Education of mothers and improvement of household incomes should be given special attention. This is because children born to uneducated mothers and from poor households have been found to have increased risk of stunting. In general, our findings are of major significance because they identify potential areas for action plans that could improve and sustain the nutritional status of children under-five years of age.

One potential limitation of the study as a secondary data analysis was that, there was no information on dietary habits or insufficient dietary practices to support stunted and severely stunted children. Another limitation was the indirect measure of household wealth in a developing country such as Nepal. It is difficult to obtain consistent income and expenditure data in this country; however, an asset-based index is generally considered a decent proxy for household wealth status.

The sampling method, appropriate adjustment for sampling design, including sampling weight and a high response rate (98%) from the survey are important strengths of this study. The study also contributes to the understanding of the factors associated with stunting and severe stunting among children 0–59 months in Nepal by using the recent 2011 Demographic and Health Survey data. For a developing country like Nepal, this study provides a foundation for planning of intervention strategies to prevent stunting in children less than five years of age. Interventional studies aimed at examining the impact of child and maternal under-nutrition are needed in Nepal and such studies should target mothers from low socioeconomic backgrounds.

Conclusions

Our analysis of factors associated with stunting and severe stunting among children 0–59 months in Nepal revealed that the common increased risk factors for stunting were combined place and mode of delivery (home delivery), prolonged breastfeeding (more than 12 months), perceived size of baby (small babies), household wealth (poorest households) while types of delivery assistance (mothers delivered by no one), prolonged breastfeeding (more than 12 months), perceived size of baby (small babies), household wealth (poorest households) reported consistenthigh risk factors for severe stunting.Our findings highlight the need for early community-based educational interventions aimed at improving the nutritional status of children underfive years of age in order to achieve optimal brain development and reduce mortality triggered by malnutrition.

Declarations

Acknowledgements

This analysis is a part of the first author’s Master of Nutrition Science and Policy thesis with the Tufts University. The first author received scholarship for her degree by the Feed the Future Food Security Innovation Lab: Collaborative Research on Nutrition which is funded by the United States Agency for International Development. We are grateful to Measure DHS, ORC Macro, Calverton, MD, USA for providing the 2011 NDHS data for this analysis.

Authors’ Affiliations

(1)
Nutrition Promotion and Consultancy Service, Kathmandu, Nepal
(2)
Friedman School of Nutrition Science and Policy, Tufts University, Medford, Massachusetts, USA
(3)
School of Science and Health, University of Western Sydney, Sydney, New South Wales, Australia

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  39. Pre-publication history

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© Tiwari et al.; licensee BioMed Central Ltd. 2014

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. 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.

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