Double Burden of Malnutrition Among Women in Reproductive Age (15-49 years) in Sierra Leone: A Secondary Data Analysis of the Demographic Health Survey of 2019 (SLDH-2019).

doi:10.21203/rs.3.rs-1992723/v1

Background

The double burden of Malnutrition globally, particularly in sub-Saharan Africa, is on the rise. In Sierra Leone, the incidence of overweight, obesity (OWOB), and overnutrition among women have recently sharply increased, in addition to undernutrition which has been prevalent for decades. This study aimed to determine the prevalence of the different Malnutrition categories (underweight, overweight, obesity, and overnutrition) with Malnutrition among women of reproductive age (15–49 years) in Sierra Leone and associated factors using secondary data analysis of the Demographic Health Survey of 2019 (SLDHS-2019).

Methods

We conducted a secondary data analysis of the Sierra Leone Demographic Health Survey (2019-SLDHS) of 7,514 women aged 15 to 49. We excluded pregnant, post-natal, lactating, and post-menopausal women. Data was collected using a validated questionnaire, and participants were selected through a multistage stratified sampling approach. A multivariable logistic regression analysis was performed to determine factors associated with the different Malnutrition categories among 15–49-year-old women in Sierra Leone.

Results

Among 15–49-year-old women in Sierra Leone, the prevalence of the different categories of Malnutrition was as follows: underweight, 6.7%(95%CI:4.5%-8.9%); overweight, 19.7%(95%CI:17.7%-21.7%); obesity, 7.4%(95% CI:5.2%-9.6%); and overnutrition, 27.1%(95%CI:25.2%-29.0%). The independent predictors of not being underweight included: age group of 25–34 years (AOR = 1.670, 95%CI:1.254–2.224;p < 0.001) unmarried (AOR = 0.594,95%CI:0.467–0.755;p < 0.001) women from the North (AOR = 0.734,95%CI:0.559–0.963;p = 0.026), and not listening to a radio (AOR = 0.673;95%CI:0.549–0.826;p < 0.001). The 25–34 years (AOR = 0.609,95%CI:0.514–0.722;p < 0.001) and 35–49 years (AOR = 0.480,95%CI:0.403–0.571;p < 0.001) age groups, unmarried women (AOR = 1.470,95%CI:1.249–1.730;p < 0.001), working-class (AOR = 0.840,95%CI:0.720–0.980;p = 0.026) coming from the North (AOR = 1.325,95%CI:1.096–1.602;p = 0.004) and South (AOR = 0.755,95%CI:0.631–0.903;p = 0.002), middle wealth index (AOR = 0.656,95%CI:0.535–0.804;p < 0.001), richer wealth index (AOR = 0.400,95%CI:0.309–0.517; p < 0.001), richest wealth index (AOR = 0.317,95%CI:0.234–0.431;p < 0.001), and not listening to a radio (AOR = 1.149; 95%CI:1.002–1.317;p = 0.047) were the independent predictors of overweight. The independent predictors of overweight among Sierra Leone women 15–49 years are the same as those of obesity or overnutrition, in addition to female-headed households (AOR = 0.717,95%CI:0.578–0.889;p < 0 .001).

Conclusion

The prevalence of all the Malnutrition categories among women of reproductive age in Sierra Leone was high, affirming the double burden of Malnutrition in this group. It was more likely to be underweight among the 15–24-year age group compared to the 25–34 and 35–49-year age groups. The independent predictors of overweight, obesity, and overnutrition were age groups of 25–34 and 35–49, unmarried/single women, working class, women from the North and South, female headed households, middle to richest wealth index, and do not listen to a radio. There is an urgent need for policymakers in Sierra Leone to design comprehensive educational campaigns for women in the reproductive age group on healthy lifestyles and the dangers of being underweight or over-nutrition.

Epidemiology

Malnutrition

Double burden of Malnutrition

Women

Sierra Leone

DHS of 2019

In 2015, approximately 9% of the world's adult population were underweight, and 30-40% were overweight or obese [1,2,3]. Women had a slightly higher prevalence of overweight and obesity (OWOB) compared to males [1,2]. Although there is a marginal decline in the prevalence of underweight [1,2], the rise in the proportion of people being overweight or obese is a global pandemic [1,2,3]. There has been a 50-80% increase in OWOB in the last 30 years [2,3]. Despite variabilities in findings, an increase in the prevalence of OWOB is in most countries, ages, socioeconomic levels, and in both sexes [1,2,3]. Both underweight and overweight affect the functioning and structures of our body organs, thus increasing the risk of mortality [4,5]. An abnormal nutritional status is one of the leading risk factors for premature death and loss of disability-adjusted life years (DALYs) [6]. Overweight and Obesity are associated with many adverse health outcomes, including type 2 diabetes mellitus, cardiovascular diseases, some types of cancers, musculoskeletal and mental health disorders, and pregnancy complications [4,7,8]. Amongst many others, undernutrition increases the risks of infections [9], pre-term births, and low birth weights of offspring [8,10].

Malnutrition, in all its different forms, affects all countries worldwide [11]. Many countries face a double burden of Malnutrition (DBM), where undernutrition and OWOB exist in the same population, communities, households, and even individuals [12]. While in high-income countries, OWOB is usually more prevalent among populations with a low socioeconomic status (SES), the opposite has been observed in low-income countries [3,13,14]. The results from a recent analysis including 126 low and middle-income countries (LMIC) showed that the increase in the global DBM was driven by countries with a low gross domestic product, as these tended to have a greater increase in OWOB and a slight decrease in the prevalence of undernutrition [3,13,14]. This increase in the DBM has also been particularly observed in Asia [12]. Most undernourished people in Africa are in the sub-Saharan region, and hunger has risen since 2014 [15]. As of 2019, the number of undernourished people has been critical in Africa's Eastern and middle subregions, reaching 27% and 29% of the total population, respectively [16]. Undernutrition and micronutrient deficiencies, however, are not the only nutrition concerns [17]. In 2016, 24% of all overweight children under five in the world were also from Africa, with rates increasing among adolescents and young women [17]. The state of Malnutrition in sub-Saharan Africa epitomizes the DBM, with a high prevalence of undernutrition and increasing obesity [17]. Both these conditions contribute to diet-related non-communicable diseases (NCDs) [17]. It is unlikely that the sub-Saharan Africa region will achieve the Sustainable Development Goals (SDGs) of ending hunger and all forms of Malnutrition by 2030 if this rate is maintained [18]. Increasingly, sub-Saharan Africa is now experiencing a DBM with high levels of undernutrition and a growing burden of overweight, Obesity, and diet-related NCDs [17]. The prevalence of undernourishment markedly increased in sub-Saharan Africa between 2010 and 2016 [17]. Although chronic undernutrition is decreasing in Africa, children under five years of age are increasingly stunted due to the rapid population growth [17]. For now, overweight and obesity are increasing in all age groups, with girls and women being more affected than boys and men [17]. Interestingly, the drivers of the DBM are known to originate from outside the health sector and operate across national and regional boundaries [17].

The increasing incidence and prevalence of DBM in many African countries drove this research team to investigate the factors associated with Malnutrition among women in the reproductive age of 15-49 years in Sierra Leone using a Sierra Leone demographic health survey data of 2019.

This study aimed to determine the prevalence of Malnutrition (underweight, overweight, Obesity and overnutrition) and factors associated with Malnutrition among women of the reproductive age (15-49 years) in Sierra Leone using secondary data analysis of the Demographic Health Survey of 2019 (SLDHS-2019).

Study design: We conducted a secondary analysis of the 2019 Sierra Leone Demographic Health Survey (2019 SLDHS) dataset.

Data collection: This data was collected from May 14, 2019, to August 31, 2019 [19]. It was a nationally representative survey carried out by the Bureau of Statistics Sierra Leone as part of the international MEASURE Demographic Health Surveys (DHS) with the support of Inner-City Fund (ICF) International and the United States Agency for International Development (USAID) [19]. SLDHS is a periodical survey conducted every five years in Sierra Leone, and this was the third survey, with the second being conducted in 2014 and the first in 2010 [19]. Five questionnaires based on the DHS Program's standard Demographic and Health Survey (DHS-7) T4 adapted to reflect the population and health issues relevant to Sierra Leone were used for the 2019 SLDHS [19]. These questionnaires include the Household Questionnaire, the Woman's Questionnaire, Man's Questionnaire, the Biomarker Questionnaire, and the Fieldworker Questionnaire [19]. The Sierra Leone Ethics and Scientific Review Committee (SLESRC) and the ICF Institutional Review Board reviewed and approved the survey protocol [19]. All questionnaires were in English, and the 2019 SLDHS used computer-assisted personal interviewing (CAPI) for data collection [19]. Household questionnaires collected data on household environment, assets, and basic demographic information of household members, while women's questionnaires collected data about women's background characteristics, reproductive health, domestic violence, and nutrition [19]. Regarding anthropometry, weight was recorded in kilograms (kg) to the nearest one decimal point and was measured using an electronic scale (SECA 878) [19]. The height of participants was measured using a stadiometer in centimeters (cm) to one decimal point [19].

Study setting: As of July 2019, Sierra Leone had a population of 8,200,00 million people, with 23.8% of the population residing in urban areas, and the country has a total land area of 78,000 km2 [20]. Sierra Leone's health system has six levels ranging from the highest level at national referral hospitals to the lowest level at the community level [21]. Agriculture contributes about 24% of gross domestic product (GDP), providing half of the export earnings, and it is the primary source of income for the 84% of Sierra Leones living in rural areas [22].

Study sampling and participants: The 2015 Population and Housing Census of the Republic of Sierra Leone conducted by Statistics Sierra Leone (Stats SL) provided the ready-made sampling frame for the 2019 SLDHS [23]. Sierra Leone is administratively divided into provinces, which are further subdivided into districts. Each district is subdivided into chiefdoms/census wards, and each chiefdom/census ward is subdivided into sections [20,21,22]. The 2015 Population and Housing census subdivided each locality into convenient census Enumeration Areas (EAs) [22,23]. The 2015 census EAs were used as the primary sampling units (PSUs) and clusters for the 2019 SLDHS [19,20,21,22,23]. The list of EAs from the 2015 Population and Housing Census formed the basis for estimating the number of households and distinguishing EAs (clusters) as urban or rural for the 2019 SLDHS sample frame [19,20,22].

The 2019 SLDHS employed a two-stage stratified sample design [19]. Stratification was achieved by separating each district into urban and rural areas [19]. In total, 31 sampling strata were created [19]. Samples were selected independently in every stratum via a two-stage selection process [19]. Implicit stratifications were achieved at each lower administrative level by sorting the sampling frame before sample selection according to administrative order and using a probability proportional-to-size selection during the first sampling stage [19]. In the first stage, 578 EAs were selected with a probability proportional to EA size [19]. Enumeration Area (EA) size was the number of households residing in the enumeration area [19]. A household listing operation was carried out in all selected enumeration areas [19]. The resulting lists of households served as a sampling frame for selecting households in the second stage [19].

In the second stage's selection, a fixed number of 24 households was selected in every cluster through equal probability systematic sampling, resulting in a total sample size of approximately 13,872 selected households, distributed in a total of 578 clusters [19]. The household listing was done using tablets, and households were selected randomly through computer programming [19]. The survey interviewers questioned only the pre-selected households in the clusters [19]. No replacements or changes of the pre-selected households were allowed in the implementing stages to prevent selection bias in the study [19]. Due to the non-proportional allocation of the sample to the different districts and the possible differences in response rates, sampling weights were calculated, added to the data file, and applied so that the results would be represented at the national level and the domain level [19]. Because the 2019 SLDHS sample was a two-stage stratified cluster sample selected from the sampling frame, sampling weights were calculated separately for each sampling stage and cluster based on sampling probabilities [19]. The 2019 SLDHS included all women aged 15-49 in the sample households [19]. Permanent residents of the selected households and visitors who stayed in the households over the night prior to the survey were eligible for interviews in the selected households [19]. The men's survey was conducted in one-half of the sample households, and all men aged 15-59 in these households were included [19]. One eligible woman in each household was randomly selected to question incidences of domestic violence in this population subsample [19].

Similarly, biomarker information was collected only in those households selected for the men's survey [19]. The biomarkers included in this survey were weight for women aged 15-49, hemoglobin testing for women aged 15-49, height, and testing for HIV for women 15-49 years [19].

Operational definitions

Body Mass Index (BMI): Weight in kilograms divided by height in meters squared.

Underweight: BMI <18.5Kg/M²

Overweight: BMI > = 25.00 Kg/M2 and < = 29.99 Kg/M²

Obese: BMI > = 30.00 Kg/M2 and < = 50.00 kg/M²

Overnutrition (Overweight and obese): BMI > = 25.00 Kg/M2 and < = 50.00 Kg/M².

Enumeration Area (Clusters): An EA is a geographic area consisting of a convenient number of dwelling units that serve as a counting unit for the census.

Statistical analysis: The SPSS analytic software version 24.0 Complex samples package was used for this analysis. The use of the complex samples package accounted for the complex survey sampling, while the use of sample weighted data accounted for the unequal probability sampling in different strata. Descriptive statistics and multivariable logistic regressions did analyze the data. Frequency tables and proportions/percentages to describe categorical variables were conducted, while means and standard deviations were for continuous variables. Initially, each exposure was assessed separately for its association with the outcome variables (underweight, overweight, Obesity, and overnutrition) using bivariate logistic regression, and we presented crude odds ratio (COR), 95% confidence interval (CI), and p-values. Independent variables found significant at a p-value less than 0.2 were added to the multivariable model [24-26]. The multivariable logistic regression models included the non-significant variables associated with being underweight, overweight, Obesity, and overnutrition, as shown in previous studies. In the multivariable logistic regression analysis, we constructed two models based on categorizing the independent variables into women's individual, household, and community factors. We first performed a logistic regression model which included only individual characteristics (age, education level, working status, and marital status). After that, we constructed a final model which included individual characteristics adjusted for household and community characteristics (wealth index, residence, region, household size, and sex of household head). Adjusted odds ratios (AOR) at 95% Confidence Intervals (CI) and p-values were calculated, with a statistical significance level set at p-value < 0.05. Sensitivity analysis with only women who were underweight and had normal BMI after excluding those with BMI above 25.

The socioeconomic characteristics of women in the reproductive age of 15-49 years (N=7,514) were in the Sierra Leone Demographic Health Survey of 2019 (SLDHS-2019).

The prevalence of Malnutrition: The total female population aged 15-49 years who participated in the 2019 demographic health survey of Sierra Leone (2019 SLDHS) was15,574. The female population aged 15-49 years with a BMI result was 48%(7,514/15,574). Among the women of reproductive age (15-49 years) with a BMI measurement, 66.2%(95% CI, 64.9%-67.5%; 4,974/7,514) had a normal result. The prevalence of the different categories of Malnutrition among these women was as follows: underweight, 6.7%(95% CI, 4.5%-8.9%; 502/7,514); overweight, 19.7% (95% CI, 17.7%-21.7%; 1,479/7,514); obesity, 7.44% (95% CI, 5.2%-9.6%; 559/7,514); and overnutrition 27.12%, (95% CI, 25.2%-29.0%; 2,038/7,514).

Sociodemographic characteristics of women in the reproductive age in Sierra Leone.

Most Sierra Leone women of reproductive age with a BMI result were in the 15-24 year age group 2,916/7,514(38.8%), parity of up to four 3,892/7,514(51.8%), of rural residence 4,422/7,514(58.9%), male headed households 5,356/7,514(71.3%), household size of six and above 4,519/7,514(60.1%), working class 5,234/7,514(69.7%), married 4,795/7,514(63.8%), from the South 1,831/7,514(24.4%), had no formal education 3,571/7,514(47.5%)_’ richer wealth index 1,634/7,514(21.7%), do not watch TV 5,625/7,514(74.9%), do not listen to radio 4,372/7,514(58.2%), do not read magazines 7,025/7,514(93.5%), do not smoke cigarettes 7,290/7,514(97.0%), and do not use alcohol 3,081/7,514(41.0%).

Weight classification of women in the reproductive age in Sierra Leone. The weight classifications of women of reproductive age in Sierra Leone with a BMI result in the 2019 SLDHS was as follows: underweight was commonest among the age group of 15-24 years, 289/7,514(3.85%); normal weight among 15-24 years, 2,137/7,514(28.44%); and overnutrition among the 35–49-year age group, 867/7,514(11.54%).

BMI classification of women in the reproductive age in Sierra Leone. The BMI classification among women in reproductive age in Sierra Leone according to the DHS-2019. The majority of the women who were found to be moderately or severely thin (BMI <17Kg/M²) were in the 20-29 year age group, 69/7,514 (0.918%); mildly thin (BMI=17.0-18.4Kg/M²) in the 40-49 year age group, 72/7,514(0.958%); normal weight (BMI=18.5-24.9Kg/M²) in the 20-29 year age group, 1173/7,514(15.61%); overweight (BMI=25.0-29.9Kg/M²) in the 30–39-year age group, 334/7,514(4.445%), in obese (BMI>30Kg/M²) 188/7,514(2.502%).

In Table 4, the independent predictors of underweight among Sierra Leone women in the reproductive age of 15-49 years were age group of 25-34 years (AOR 1.670; 95% CI 1.254-2.224; p<0.001), unmarried/single (AOR 0.594; 95% CI 0.467-0.755; p<0.001), women from the North (AOR 0.734; 95% CI 0.559-0.963; p=0.026), and do not listen to a radio (AOR 0.673; 95% CI 0.549-0.826; p<0.001).

The independent predictors of overweight among women of reproductive age in Sierra Leone.

The independent predictors of overweight among Sierra Leone women in the reproductive age were age group of 25-34 years (AOR 0.609; 95% CI 0.514-0.722; p<0.001), 35-49 year age group (AOR 0.480; 95% CI 0.403-0.571; p<0.001), unmarried/single women (AOR 1.470; 95% CI 1.249-1.730; p<0.001), working-class women (AOR 0.840; 95% CI 0.720-0.980; p<0.026), women from the North (AOR 1.325; 95% CI 1.096-1.602; p=0.004), women from the South (AOR 0.755; 95% CI 0.631-0.903; p=0.002), middle wealth index (AOR 0.656; 95% CI 0.535-0.804; p<0.001), richer wealth index (AOR 0.400; 95% CI 0.309-0.517; p<0.001), richest wealth index (AOR 0.317; 95% CI 0.234-0.431; p<0.001), and do not listen to a radio (AOR 1.149; 95% CI 1.002-1.317; p<0.047).

The independent predictors of obesity among women of reproductive age in Sierra Leone.

The independent predictors of obesity among Sierra Leone women in the reproductive age, 15-49 years, were 25-34 year age group (AOR 0.609; 95% CI 0.514-0.722; p<0.001), 35-49 year age group (AOR 0.480; 95% CI 0.403-0.571; p<0.001), female headed household (AOR 0.717; 95% CI 0.578-0.889; p<0.001), working-class women (AOR 0.840; 95% CI 0.720-0.980; p<0.026), women from the North (AOR 1.447; 95% CI 1.054-1.985; p=0.022), women from the South (AOR 0.740; 95% CI 0.552-0.991; p=0.043), middle wealth index (AOR 0.418; 95% CI 0.283-0.618; p<0.001), richer wealth index (AOR 0.156; 95% CI 0.101-0.242; p<0.001), richest wealth index (AOR 0.095; 95% CI 0.058-0.155; p<0.001), and do not listen to a radio (AOR 1.370; 95% CI 1.105-1.699; p<0.004).

The independent predictors of overnutrition among women of reproductive age in Sierra Leone.

The independent predictors of overnutrition among women in Sierra Leone were 25-34 year age group (AOR 0.512; 95% CI 0.438-0.599; p<0.001), 35-49 year age group (AOR 0.350; 95% CI 0.298-0.41; p<0.001), female headed households (AOR 0.836; 95% CI 0.736-0.950; p<0.006), working-class women (AOR 0.840; 95% CI 0.720-0.980; p<0.026), unmarried/single woman (AOR 1.432; 95% CI 1.235-1.660; p<0.001), women from the North (AOR 1.359; 95% CI 1.143-1.660; p=0.001), women from the South (AOR 0.750; 95% CI 0.637-0.884; p=0.001), middle wealth index (AOR 0.603; 95% CI 0.499-0.728; p<0.001), richer wealth index (AOR 0.333; 95% CI 0.264-0.42; p<0.001), richest wealth index (AOR 0.248; 95% CI 0.188-0.326; p<0.001), and not listening to a radio (AOR 1.201; 95% CI 1.061-1.359; p<0.004).

The frequency of underweight, overweight, and obesity by age groups among women in reproductive age in Sierra Leone.

Underweight was commonest among women aged 15-24 years, overweight in the 35–49-year-old, obese in the 35–49-year age group, and over nourished in the 35–49-year age group.

Table 1: The sociodemographic characteristics of women of reproductive age in Sierra Leone (15-49 years).

Variable	Frequency (N=7,514)	Percent (%)
Ages (years)
15-24	2,916	38.8
25-34	2,176	29.0
35-49	2,422	32.2
Parity
Never gave birth	1,895	25.2
Up to 4	3,892	51.8
Five and above	1,727	23
Residence
Urban	3,092	41.1
Rural	4,422	58.9
Sex household head
Male	5,356	71.3
Female	2,158	28.7
Household size
Less than 6	2,995	39.9
Six and above	4,519	60.1
Work status
Not working	2,280	30.3
Working	5,234	69.7
Marital status
Married	4,795	63.8
Not Married	2,719	36.2
Region
East	1,579	21.0
North	1,822	24.2
Northwest	1,026	13.7
South	1,831	24.4
Western	1,256	16.7
Education
No formal educated	3,571	47.5
Primary	1,017	13.5
Secondary	2,641	35.2
Higher	285	3.8
Wealth Index
Poorest	1,533	20.4
Poorer	1,428	19.0
Middle	1,531	20.4
Richer	1,634	21.7
Richest	1,388	18.5
Watching TV
Yes	1,889	25.1
No	5,625	74.9
Listening to radio
Yes	3,142	41.8
No	4,372	58.2
Reading Magazine
Yes	489	6.5
No	7.025	93.5
Smoking
Yes	224	3.0
No	7,290	97.0
Alcohol use
Yes	667	8.88
No	3,081	41.00

The data source is SLDHS-2019.

Table 1 shows that most Sierra Leone women of reproductive age were in the 15-24 year age group 2,916/7,514(38.8%), parity of up to four 3,892/7,514(51.8%), of rural residence 4,422/7,514(58.9%), male being the head of household 5,356/7,514(71.3%), household size of six and above 4,519/7,514(60.1%), working class 5,234/7,514(69.7%), married 4,795/7,514(63.8%), from the South 1,831/7,514(24.4%), had no formal education 3,571/7,514(47.5%); richer within the wealth index 1,634/7,514(21.7%); do not watch TV 5,625/7,514(74.9%); do not listen to radios 4,372/7,514(58.2%), do not read magazines 7,025/7,514(93.5%), do not smoke cigarettes 7,290/7,514(97.0%), and do not use alcohol 3,081/7,514(41.0%).

Table 2: Descriptive statistics for the weight categories of participants in the 2019 SLDHS.

	Underweight		Normal weight		Over nourished
Variables	Freq (N=7,514)	(Percent) %	Freq (N=7,514)	(Percent) %	Freq (N=7,514)	(Percent) %
Ages (years)
15-24	289	3.85	2,137	28.44	490	6.52
25-34	84	1.12	1,411	18.78	681	9.06
35-49	129	1.72	1,426	18.98	867	11.54
Parity
Never gave birth	225	2.99	1,330	17.70	340	4.52
Up to 4	182	2.42	2,537	33.76	1,173	15.61
Five and above	95	1.26	1,107	14.73	525	6.99
Residence		0.00		0.00		0.00
Urban	162	2.16	1,818	24.19	1112	14.80
Rural	340	4.52	3,156	42.00	926	12.32
Sex of the household head
Male	343	4.56	3,621	48.19	1392	18.53
Female	159	2.12	1,353	18.01	646	8.60
Household size		0.00		0.00		0.00
Less than 6	181	2.41	1,976	26.30	838	11.15
Six and above	321	4.27	2,998	39.90	1,200	15.97
Work status
Not working	191	2.54	1,529	20.35	560	7.45
Working	311	4.14	3,445	45.85	1,478	19.67
Marital status		0.00		0.00		0.00
Married	232	3.09	3,102	41.28	1,461	19.44
Not Married	270	3.59	1,872	24.91	270	3.59
Region
East	96	1.28	1,082	14.40	402	5.35
North	153	2.04	1,305	17.37	364	4.84
Northwest	73	0.97	724	9.64	229	3.05
South	134	1.78	1,173	15.61	524	6.97
Western	10	0.13	690	9.18	520	6.92
Level of education
No formal educated	211	2.81	2,399	31.93	961	12.79
Primary	96	1.28	686	9.13	235	3.13
Secondary	185	2.46	1,755	23.36	701	9.33
Higher	10	0.13	134	1.78	141	1.88
Wealth Index
Poorest	104	1.38	1,156	15.38	273	3.63
Poorer	120	1.60	1,053	14.01	255	3.39
Middle	121	1.61	1,050	13.97	360	4.79
Richer	97	1.29	974	12.96	563	7.49
Richest	60	0.80	741	9.86	587	7.81
Watching TV
Yes	98	1.30	1,123	14.95	688	9.16
No	404	5.38	3,851	51.25	1370	18.23
Listening to radio
Yes	152	2.02	1,967	26.18	1023	13.61
No	350	4.66	3,007	40.02	1015	13.51
Reading Magazine
Yes	29	0.39	276	3.67	184	2.45
No	473	6.29	4,698	62.52	1854	24.67
Smoking cigarettes
Yes	18	0.24	139	1.85	67	0.89
No	484	6.44	4,835	64.35	1971	26.23
Alcohol use
Yes	35	0.47	429	5.71	203	2.70
No	140	1.86	2,005	26.68	936	12.46

The data source is SLDHS-2019.

Table 2 shows the weight classifications of women of reproductive age in Sierra Leone as per the SLDHS of 2019. Underweight was commonest among the age group of 15-24 years 289/7,514(3.85%); normal weight among 15-24 years 2,137/7,514(28.44%) and over nourished among 35–49-year age group 867/7,514(11.54%).

Table 3: The BMI classification among women of reproductive age in Sierra Leone (SLDHS-2019).

Variables	Moderately and severely thin (BMI <17) (N=7,514)	Mildly thin (BMI 17.0-18.4) (N=7,514)	Normal weight (BMI=18.5-24.9) (N=7,514)	Overweight (BMI=25.0-29.9) (N=7,514)	Obese (BMI>30) (N=7,514)
Ages (years)
15-19	4(0.053)	18(0.240)	207(2.75)	26(0.346)	8(0.106)
20-29	69(0.918)	0(0.00)	1,173(15.61)	334(4.445)	92(1.224)
30-39	20(0.266)	69(0.918)	1,099(14.63)	411(5.47)	188(2.502)
40-49	18(0.240)	72(0.958)	738(9.82)	290(3.86)	169(2.249)
Parity
Never gave birth	41(0.546)	169(2.249)	1,330 (17.70)	271 (3.607)	69 (0.918)
Up to 4	34(0.452)	134(1.783)	2537 (33.76)	844 (11.232)	329 (4.378)
Five and above	18(0.240)	71(0.945)	1,107 (14.73)	364 (4.844)	161 (2.143)
Residence
Urban	10(0.133)	51(0.679)	960(12.78)	519(6.907)	282(3.753)
Rural	40(0.532)	160(2.129)	2,257(30.04)	542(7.213)	175(2.329)
The sex of the household head
Male	35(0.466)	149(1.983)	2,422(32.23)	734(9.768)	288(3.833)
Female	15(0.200)	62(0.825)	581(7.73)	327(4.352)	169(2.249)
Household size
Less than 6	25(0.333)	80(1.065)	1,368(18.21)	467(6.215)	179(2.382)
Six and above	25(0.333)	131(1.743)	1,849(24.61)	594(7.905)	278(3.700)
Work status
Not working	7(0.093)	39(0.519)	583(7.76)	206(2.742)	103(1.371)
Working	43(0.572)	172(2.289)	2,634(35.05)	855(11.379)	354(4.711)
Marital status
Married	41(0.546)	169(2.249)	2,566(34.15)	858(11.419)	356(4.738)
Not Married	9(0.120)	42(0.559)	651(8.66)	203(2.702)	101(1.344)
Region
East	10(0.133)	50(0.665)	702(9.34)	220(2.928)	88(1.171)
North	12(0.160)	48(0.639)	873(11.62)	203(2.702)	67(0.892)
Northwest	6(0.080)	37(0.492)	480(6.39)	122(1.624)	49(0.652)
South	16(0.213)	63(0.838)	782(10.41)	290(3.859)	115(1.530)
Western	6(0.080)	13(0.173)	380(5.06)	226(3.008)	138(1.837)
Level of education
No formal education	33(0.439)	129(1.717)	1,983(26.39)	538(7.160)	235(3.127)
Primary	7(0.093)	25(0.333)	412(5.48)	136(1.810)	47(0.625)
Secondary	9(0.120)	52(0.692)	740(9.85)	288(3.833)	125(1.664)
Higher	2(0.027)	5(0.067)	82(1.09)	54(0.719)	50(0.665)
Wealth index
Poorest	8(0.106)	59(0.785)	839(11.17)	180(2.396)	39(0.519)
Poorer	16(0.123)	64(0.852)	767(10.21)	43(0.572)	43(0.519)
Middle	17(0.226)	38(0.506)	720(9.58)	68(0.905)	68(0.905)
Richer	30(0.399)	30(0.399)	528(7.03)	141(1.876)	141(1.876)
Richest	1(0.013)	20(0.266)	363(4.83)	166(2.209)	166(2.209)
Watching TV
Yes	5(0.067)	31(0.413)	603(8.03)	304(4.046)	171(2.276)
No	45(0.599)	180(2.396)	2,614(34.79)	757(10.075)	2863.806)
Listening to radio
Yes	12(0.160)	70(0.932)	1,210(16.10)	501(6.668)	256(3.407)
No	38(0.506)	141(1.876)	2,007(26.71)	560(7.453)	201(2.675)
Reading Magazine
Yes	3(0.040)	7(0.093)	132(1.76)	67(0.892)	46(0.612)
No	47(0.625)	204(2.715)	3,085(41.06)	994(13.229)	411(5.470)
Smoking
Yes	2(0.027)	14(0.186)	121(1.61)	39(0.519)	16(0.213)
No	48(0.639)	197(2.622)	3,096(41.20)	1.022(13.601)	441(5.869)
Alcohol use
Yes	3(0.040)	30(0.399)	370(4.92)	124(1.650)	44(0.586)
No	30(0.399)	99(1.318)	1,639(21.81)	556(7.400)	229(3.048)

The data source is SLDHS-2019.

Table 3 shows the BMI classification among women in reproductive age in Sierra Leone according to the DHS-2019. The majority who were moderately and severely thin (BMI <17Kg/M²) were in the age group of 20-29 years 69/7,514(0.918%); mildly thin (BMI=17.0-18.4Kg/M²) in 40-49 years 72/7,514(0.958%); normal weight (BMI=18.5-24.9Kg/M²) in 20-29 years 1173/7,514(15.61%); Overweight (BMI=25.0-29.9Kg/M²) in 30–39-year age group 334/7,514(4.445%), in Obese (BMI>30Kg/M²) 188/7,514(2.502%).

Table 4: Prevalence and predictors of underweight (BMI<18.5Kg/M²) among participants.

Variables	Underweight (N=502) (n, %)	Normal weight N= (4,974) n (%)	Unadjusted COR	95% CI	p value	Adjusted POR	95% CI	p value
Ages (years)
15-24	289(11.9)	2,137(88.1)	Reference			Reference
25-34	84(5.6)	1,411(94.4)	2.272	(1.765-2.923)	<.001	1.670	(1.254-2.224)	<.001
35-49	129(8.3)	1,426(91.7)	1.495	(1.202-1.859)	<.001	1.136	(0.870-1.483)	.350
Parity
0 – 4	407(9.5)	3,867(90.5)	Reference
Five and above	95(7.9)	1,107(92.1)	1.226	(0.971-1.548)	.086
Residence
Urban	162(8.2)	1,818(91.8)	Reference
Rural	340(9.7)	3,156(90.3)	0.827	(0.680-1.006)	.057
Sex household head
Male	343(8.7)	3,621(91.3)	Reference			Reference
Female	159(10.5)	1,353(89.5)	0.806	(0.661-0.983)	.033	0.925	(0.750-1.141)	.469
Household size
Less than 6	181(8.4)	1,976(91.6)	Reference
Six and above	321(9.7)	2,998(90.3)	0.855	(0.707-1.035)	.109
Work status
Not working	191(11.1)	1,529(88.90	Reference
Working	311(8.3)	3,445(91.7)	1.384	(1.144-1.673)	.001	1.082	(0.868-1.349)	.481
Marital status
Married	232(7.0)	3,102(93.0)	Reference
Not Married	270(12.6)	1,872(87.4)	0.519	(0.431-0.624)	<.001	0.594	(0.467-0.755)	<.001
Region
East	96(8.1)	1,082(91.9)	Reference			Reference
North	153(10.5)	1,305(89.5)	0.757	(0.579-0.989)	.041	0.734	(0.559-0.963)	.026
Northwest	73(9.2)	724(90.8)	0.88	(0.640-1.210)	.431	0.840	(0.609-1.160)	.290
South	134(10.3)	1,173(89.7)	0.777	(0.590-1.022)	.071	0.776	(0.588-1.204)	.073
Western	46(6.2)	690(93.8)	1.331	(0.925-1.916)	.777	1.385	(0.954-2.011)	.087
Education
No educated	211(8.1)	2,399(91.9)	Reference
Primary	96(12.3)	686(87.7)	0.628	(0.487-0.812)	<.001
Secondary	185(9.5)	1,755(90.5)	0.834	(0.679-1.026)	.086
Higher	10(6.9)	134(93.1)	1.179	(0.611-2.275)	.624
Wealth Index
Poorest	104(8.3)	1,156(91.7)	Reference
Poorer	120(10.2)	1,053(89.8)	.789	(0.599-1.040)	.093
Middle	121(10.3)	1,050(89.7)	.781	(0.593-1.028)	.078
Richer	97(9.1)	974(90.9)	.903	(0.676-1.207)	.491
Richest	60(7.5)	741(92.5)	1.111	(0.798-1.547)	.533
Watching TV
Yes	98(8.0)	1,123(92.0)	Reference
No	404(9.5)	3,851(90.5)	0.832	(0.661-1.047)	.117
Listens to radio
Yes	152(7.2)	1,967(92.8)	Reference
No	350(10.4)	3,007(89.6)	0.664	(0.544-0.810)	<.001	0.673	(0.549-0.826)	<.001
Reading Magazine
Yes	29(9.5)	276(90.5)	Reference
No	473(9.1)	4,698(90.9)	1.044	(0.704-1.548)	.832
Smokes cigarettes
Yes	18(11.5)	139(88.5)	Reference
No	484(9.1)	4,835(90.9)	1.294	(0.785-2.132)	.313
Alcohol use
Yes	35(7.5)	429(92.5)	Reference
No	140(6.7)	2,005(93.3)	1.168	(0.795-1.717)	.428

The data source is SLDHS-2019.

AOR: Adjusted Odds Ratio; CI: Confidence Interval; COR: Crude Odds Ratio; SLDHS: Sierra Leone Demographic Health Survey.

In Table 4, the independent predictors of underweight among Sierra Leone women in the reproductive age of 15-49 years were age group of 25-34 years (AOR 1.670; 95% CI 1.254-2.224; p<0.001), unmarried/single (AOR 0.594; 95% CI 0.467-0.755; p<0.001), Women from the North (AOR 0.734; 95% CI 0.559-0.963; p=0.026), and do not listen to radios (AOR 0.673; 95% CI 0.549-0.826; p<0.001).

Table 5: The prevalence and predictors of overweight (BMI=25-29.99Kg/M²) among women in Sierra Leone.

Variables	Overweight (N=1,479) (n, %)	Normal weight N= (4,974) n (%)	Unadjusted COR	95% CI	p value	Adjusted OR	95% CI	p value
Ages (years)
15-24	411(16.1)	2,137(83.9)	Reference			Reference
25-34	503(26.3)	1,411(73.7)	0.540	(0.466-0.625)	<.001	0.609	(0.514-0.722)	<.001
35-49	565(28.4)	1,426(71.6)	0.485	(0.420-0.560)	<.001	0.480	(0.403-0.571)	<.001
Parity
0-4 Children	1,115(22.4)	3,867(77.6)	Reference
Five and above	364(24.7)	1,107(75.3)	0.765	(0.756-1.005)	.058
Residence
Urban	753(29.3)	1,818(70.7)	Reference			Reference
Rural	726(18.7)	3,156(81.3)	1.801	(1.601-2.024)	<.001	1.049	(0.851-1.292)	0.653
Sex of the household head
Male	1,041(22.2)	3,621(77.7)	Reference			Reference
Female	438(24.5)	1,353(75.5)	0.806	(0.661-0.983)	.033	0.893	(0.776-1.029)	.119
Household size
Less than 6	615(23.7)	1,976(76.3)	Reference
Six and above	864(22.4)	2,998(77.6)	1.080	(0.960-1.215)	.201
Work status
Not working	400(20.7)	1,529(79.3)	Reference			Reference
Working	1,079(23.9)	3,445(76.1)	0.835	(0.734-0.951)	.006	0.840	(0.720-0.980)	.026
Marital status
Married	1,058(25.4)	3,102(74.6)	Reference			Reference
Not Married	421(18.4)	1,872(81.6)	1.517	(1.336-1.721)	<.001	1.470	(1.249-1.730)	<.001
Region
East	297(21.5)	1,082(78.5)	Reference			Reference
North	278(17.6)	1,305(82.4)	1.289	(1.074-1.546)	.006	1.325	(1.096-1.602)	.004
Northwest	169(18.9)	724(81.1)	1.176	(0.952-1.452)	.132	1.164	(0.936-1.449)	.171
South	394(25.1)	1,173(74.9)	0.817	(0.688-0.970)	.021	0.755	(0.631-0.903)	.002
Western	341(33.1)	690(66.9)	0.555	(0.463-0.667)	<.001	0.922	(0.741-1.147)	.465
Level of education
No educated	699(8.1)	2,399(77.4)	Reference
Primary	180(12.3)	686(79.2)	1.110	(0.923-1.335)	.266
Secondary	521(9.5)	1,755(77.1)	0.981	(0.863-1.117)	.777
Higher	79(6.9)	134(62.9)	0.494	(0.370-0.661)	<.001
Wealth Index
Poorest	229(16.5)	1,156(83.5)	Reference			Reference
Poorer	204(16.2)	1,053(83.8)	1.023	(0.832-1.257)	0.832	0.943	(0.763-1.165)	.587
Middle	279(21.0)	1,050(79.0)	0.746	(0.614-0.905)	.003	0.656	(0.535-0.804)	<.001
Richer	390(28.6)	974(71.4)	0.495	(0.412-0.595)	<.001	0.400	(0.309-0.517)	<.001
Richest	377(33.7)	741(66.3)	0.389	(0.323-0.470)	<.001	0.317	(0.234-0.431)	<.001
Watching TV
Yes	454(28.8)	1,123(71.2)	Reference			Reference
No	1,025(21.0)	3,851(79.0)	1.519	(1.335-1.728)	<.001	0.979	(0.821-1.168)	.817
Listens to radio
Yes	708(26.5)	1,967(73.5)	Reference			Reference
No	771(20.4)	3,007(79.6)	1.404	(1.249-1.578)	<.001	1.149	(1.002-1.317)	.047
Reading Magazine
Yes	120(30.3)	276(69.7)	Reference			Reference
No	1,359(22.4)	4,698(77.6)	1.503	(1.203-1.878)	<.001	1.188	(0.926-1.525)	.176
Smokes cigarettes
Yes	46(24.9)	139(75.1)	Reference
No	1,433(22.9)	4,835(77.1)	1.117	(0.796-1.566)	.523
Alcohol use
Yes	149(25.8)	429(74.2)	Reference
No	686(25.5)	2,005(74.5)	1.015	(0.827-1.247)	.886

In Table 5, the independent predictor of overweight among Sierra Leone women in the reproductive age were age group of 25-34 years (AOR 0.609; 95% CI 0.514-0.722; p<0.001), 35-49 years (AOR 0.480; 95% CI 0.403-0.57; p<0.001), unmarried/single women (AOR 1.470; 95% CI 1.249-1.730; p<0.001), working-class women (AOR 0.840; 95% CI 0.720-0.980; p<0.026), women from the North (AOR 1.325; 95% CI 1.096-1.602; p=0.004), women from the South (AOR 0.755; 95% CI 0.631-0.903; p=0.002), middle wealth index (AOR 0.656; 95% CI 0.535-0.804; p<0.001), richer wealth index (AOR 0.400; 95% CI 0.309-0.517; p<0.001), richest wealth index (AOR 0.317; 95% CI 0.234-0.431; p<0.001), and do not listen to radios (AOR 1.149; 95% CI 1.002-1.317; p<0.047).

Table 6: The prevalence and predictors of obesity (BMI =>30kg/M²) among women in Sierra Leone.

Variables	Obese (N=559) (n, %)	Normal weight N= (4,974) (%)	Unadjusted POR	95% CI	p value	Adjusted POR	95% CI	p value
Ages (years)
15-24	79(3.6)	2,137(96.4)	Reference			Reference
25-34	178(11.2)	1,411(88.8)	0.293	(0.223-0.385)	<.001	0.265	(0.196-0.359)	<.001
35-49	302(17.5)	1,426(82.5)	0.175	(0.135-0.226)	<.001	0.122	(0.090-0.164)	<.001
Parity
0-4 Children	398(9.3)	3,867(90.7)	Reference
Five and above	161(12.7)	1,107(87.3)	0.708	(0.582-0.860)	.001	1.243	(0.976-1.583)	.078
Residence
Urban	359(16.5)	1,818(83.5)	Reference			Reference
Rural	200(6.0)	3,156(94.0)	3.116	(2.597-3.739)	<.001	0.977	(0.706-1.353)	.889
Sex of the household head
Male	351(351)	3,621(91.2)	Reference			Reference
Female	208(208)	1,353(86.7)	0.631	(0.525-0.757)	<.001	0.717	(0.578-0.889)	.002
Household size
Less than 6	223(10.1)	1,976(89.9)	Reference
Six and above	336(10.1)	2,998(89.9)	1.007	(0.842-1.204)	0.939
Work status
Not working	160(9.5)	1,529(90.5)	Reference
Working	399(10.4)	3,445(89.6)	0.904	(0.745-1.096)	.303
Marital status
Married	403(11.5)	3,102(88.5)	Reference			Reference
Not Married	156(7.7)	1,872(92.3)	1.559	(1.285-1.892)	<.001	1.293	(1.001-1.669)	<.049
Region
East	104(8.8)	1,082(91.2)	Reference			Reference
North	86(6.2)	1,305(93.8)	1.459	(1.084-1.963)	.013	1.447	(1.054-1.985)	.022
Northwest	60(7.7)	724(92.3)	1.160	(0.833-1.616)	.381	1.107	(0.777-1.577)	.573
South	130(10.0)	1,173(90.0)	0.867	(0.662-1.137)	.303	0.740	(0.552-0.991)	.043
Western	179(20.6)	690(79.4)	0.371	(0.286-0.480)	<.001	0.857	(0.628-1.169)	.331
Education
No formal educated	262(9.8)	2,399(90.2)	Reference

Double Burden of Malnutrition Among Women in Reproductive Age (15-49 years) in Sierra Leone: A Secondary Data Analysis of the Demographic Health Survey of 2019 (SLDH-2019).

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

Introduction

Methods

Results