The objective of this study was to present the distribution of wasting according to socio-demographic circumstances with a focus on household food insecurity and to measure the risk of wasting as determined by those risk. In this study, the prevalence of wasting among children under five years increased with the levels of food insecurity from mild (9.4%) to moderate (10.8%) and to severe (11.3%) food insecurity steadily, which is in accordance with the study of John et al. reporting a dose-response relation between severity of food insecurity and children’s nutritional health [22]. Another study done in low and middle income countries such as Bangladesh and Vietnam found that moderate and severe food insecurities were significantly associated with wasting [23]. However, no significant association was found in the present study although the prevalence increased incrementally with level of food insecurity. This was surprising given the already established association of food insecurity and children nutritional status by United Nations Children Fund conceptual framework of undernutrition. It could have been due to the small intersection sample size between wasted children and children belonging to food insecure households. A larger study is recommended to further understand this relationship in Nepal. Alternatively, it also could be due to confounders that could influence wasting such as knowledge of mothers on nutrition, health seeking behaviors, maternal nutritional status, access to health services, and quality of environmental conditions such as maintenance of hygiene and availability of sanitation facilities. Attention should be drawn in reducing food insecurities in order to combat the problem of wasting considering more than half of the population of Nepal are suffering from food insecurity, particularly focusing on rural areas and poor people where the severity is high. Government of Nepal has made several attempts to improve food security. Right to Food and Food Sovereignty Act 2018 was declared as fundamental right as per the 18.3 constituents of interim constitution of Nepal [24]. This act demands all citizens shall have the right to food and right to food security and aims to protect people from the negative effects of increasing food insecurity, uneven distribution of food and lack of access to food [12]. Further to this, the act seeks to support to achieve Sustainable Development Goal 2 to bring hunger to zero level. Besides, in collaboration with United States Agency for International Development, 14 most vulnerable districts in the west and 11 districts in the east have been supported for improving food security through livelihood interventions and building resilience to mitigate impacts of climate change [15]. Similarly, other organization such as the World Food Program is strengthening the capacity of government in improving food security, nutrition, as well as emergency preparedness and response, in order to support country achieve Zero Hunger and to move further from low income country to a lower middle-income country by 2023 [25]. Apart from interventions addressing food insecurity, integrated interventions are implemented in the nation after release of Multi-sector Nutrition Plan I and II that addresses education, sanitation, feeding behavior of sub-groups in population such as adolescent girls, pregnant and lactating women and their infants among the rural and poorer and poorest groups [26]. However, the high prevalence of wasting and food insecurity is still a challenge to the nation that needs to be sincerely taken care of.
The thematic report on food security and nutrition had shown greater prevalence of wasting in female (36.1%) than male children (33.8%), which contradicts the findings of the present study showing similar prevalence of wasting among male (9.5%) and female (9.7%) children. Harding et al., reported that sex was not significantly associated with wasting in Nepal aligning with the present study [27]. However, they also noted that the association was noted significant in data of other low income countries such as Afghanistan, India, Bangladesh, and Pakistan [27].
The prevalence of wasting among the wealth quintiles is not uniform. The lowest prevalence was noted in the richest quintile (7.2%) and highest prevalence was noted in richer quintile (11.3%) in 2016. Additionally, the prevalence was 8.7 percent among those belonging to the poorest quintile, which is unexpectedly close to the prevalence of wasting among children belonging to the richest quintile (7.2%) and also represents the second lowest prevalence rate among the wealth quintiles. In 2011, the lowest prevalence of wasting was among the richest quintile with 7.4 percent and the highest was among the middle quintile with 12.8 percent. . , The prevalence of wasting among children under five peaked at middle (12.8%) and then at the poorest (12.5%) quintiles [7]. The highest prevalence of wasting shifted from the middle quintile in 2011 to richer quintile in 2016. The second highest prevalence of wasting was among the poorest in 2011, which turned out to be second lowest prevalence in another five years. This might be due to a shift of overall population belonging to the poorest and poorer quintiles towards middle and richer quintile as a part of a rise in economic condition as characterized by data on Gross Domestic Product (GDP) from The World Bank [28]. The GDP has risen from 18.9 to 21.2 to 28.8 from 2011 to 2016 and to 2018 respectively [28]. Also, no significant relationship was found between wasting and wealth quintiles in this study as in other previous studies [29-34]. This finding is supported by a study on trends in stunting with four NDHSs, which has also shown reduction from 25.7 to 20.5 percent from 2011 to 2016 in proportion of stunted children under five years age among those belonging to a poorer quintile whereas an increment was observed among those belonging to a richer quintile from 16.9 to 21.7 percent [32]. However, a multinational cohort study conducted in Ethiopia, India, Peru and Vietnam found children belonging to the lowest quintile households had significantly increased probabilities of being wasted in all four countries in comparison to children belonging to the highest quintile households [35]. This is not consistent with the result of the present study having noted higher prevalence of wasting among middle and richer quintiles children.
The highest prevalence of wasting was also noted among Province 2, which might be due to large volume of underprivileged people living in Province 2 suffering from lack of basic facilities such as education and health [36]. Additionally, Nepal Multidimensional Poverty Index 2018 reports more than 47.9 percent of people living in Province 2 (second highest populated province holding 18.4%) are multi-dimensionally poor, which is greater by almost 20 percent than that of the national average (28.6%) [37]. The Demographic and Health Surveys of 15 sub-Saharan African countries showed that urban–rural differentials are considerable in all countries, that they have narrowed in most countries primarily due to an increase in urban undernutrition [38]. An another study done in Nepal mentioned that a significantly higher prevalence of wasting was noted in rural areas as compared to urban areas [39]. Aligning with these studies, the prevalence of wasting in the present study was slightly higher among children living in rural (10.1%) than those living in urban (9.2%). The better availability of health and sanitation facilities and good education among people living in urban areas on taking care of children might be reasons for low prevalence of wasting in urban areas than the rural areas [34]. Moreover, the highest proportion of wasted children were born to a mother without education (12.4%), which is similar to the finding of a thematic report on nutrition and food security stating the highest proportion (43.3%) of the undernourished children born to a mother without education [39]. A study done by Asfaw and team in Southern region of Ethiopia shows a significant association between mother's education and all three indicators of undernutrition (stunting, wasting and underweight) [40] again in agreement with the present study. Educated mothers have good knowledge on child care, are likely to take care of sanitation and follow hygiene adequately helping to improve the nutritional status of their children [41].
Due to cross-sectional nature of the study, the causal inference between wasting and study variables could not be estimated. However, this study has given provincial level information on wasting, which is not available in other studies of Nepal and is highly beneficial for formulating provincial level policies. The provincial level information on wasting would bring the focus on the current need of each province and this information would support the design of intervention within various provinces. The study warrant a high precision of the findings due to large a sample size representing national population. Reliable and comparable standardized tools were used.