Malnutrition is a universal problem, and the impact varies between regions and countries. Out of the eight key nutrition indicators to track the progress of malnutrition, three are in children namely childhood stunting, wasting and obesity . The WHO sustainable development goal targets for 2025 are to reduce stunting in childhood by 40%, no increase in obesity and reduce and maintain childhood wasting to less than 5% . Nutritional problems are multiple, and it is clearly seen from the results of our study as well.
Stunting in early childhood has shown to increases the risk of dying from childhood illnesses, impairs cognitive development, lower the educational performance and reducing job opportunities later in life. Stunting can be accompanied by later excessive weight gain thus increasing the risk of developing obesity and NCD as adults. According to the National surveys and UNICEF/WHO/World Bank Group Joint Child Malnutrition report, it is estimated that 35% of the children would be stunted in the South-East Asian region and 17.3% in Sri Lanka . Our study done in a single district in the North shows stunting in 10.9% of boys and 11.8% of girls. A similar study done in Colombo district showed stunting in 5.1% of boys and 5.2% of girls . Low prevalence of stunting in two districts may be influenced by the demography where both these districts are urban, and the economic status and educational level of the population is higher. 
Wasting is also a major issue in most countries in the region. Although most countries in the region have shown an economic growth, there are other factors such as traditional food habits, poor infant feeding practices, inadequate clean water and sanitation, and farming a limited variety of crops are some of the contributory factors. Globally the incidence of wasting is 7.3% and the South East region has 15% . Our study showed wasting in 30.6% of the boys and 29.1% in girls. This may be due to food insecurity and lack of knowledge on healthy eating habits. Poor living standards in certain areas and risk of infections can also contribute to wasting.
Obesity and overweight are the identified nutritional problem that is increasing in alarming rates in this part of the world. The World Health Organization (WHO) has stated that in 2016 the number of overweight children under the age of five, is estimated to be over 41 million and the commonly affected continents are Asia and Africa . The overall prevalence of overweight and obesity among school children in European countries was estimated at 20.5% . The prevalence of obesity in USA was 18.5% and affected about 13.7 million children and adolescents according to the Centre for Disease Control (CDC) report from 2017.
The proportion of overweight and obesity was 24.5% in Eastern Asia countries and 11.9% in the Western Asia regions .
A study done in the Colombo district shows a prevalence of obesity in boys was 4.3% and 3.1% in girls while our study indicated 8.7% in boys and 4.1% in girls . The difference even years apart may be explained by the economic status of the populations. The prevalence of overweight and obesity combined was 17.3% and it almost matches the other Asian countries . Rate of overweight and obesity and the high prevalence of under-nutrition demonstrates the existence of double burden of malnutrition in this part of the country.
A meta-analysis and systematic review done on Asian countries shows a significant higher percentage of boys (7.0%) are obese than girls (4.8%) . Our data also demonstrated a significant difference between girls and boys when considering obesity. The Global Burden of Disease Study estimated that the prevalence of obesity/overweight in children and adolescents in developing countries was 12.9% for boys and 13.4% for girls in 2013 .
The Mean Z scores for height and weight are closer to zero hence the distribution is more homogenous. When classifying the problem of malnutrition, the WHO has defined it as low, medium and high severity based on the prevalence . Prevalence of stunting <20% indicates it as low and our study population has a low prevalence (11.3%) of stunting. Similarly, for wasting if the prevalence is <5% it is low, 5-9% is medium, 10-14% is high and >15 is very high. In our study population the prevalence was 29.8% indicating a very high prevalence.
There are several socio-demographic factors contributing to malnutrition in a population. Maternal literacy is an important factor for nutritional status of children in developing countries [25, 26]. We were able to demonstrate maternal educational level and family income to have a significant association with stunting, wasting, overweight and obesity. Low level of education was associated with poor nutritional status. These results were consistent with studies done in other parts of the globe . Employment status of the mothers also contribute to the nutritional status of the children, but we were unable to demonstrate this fact in our population. In our study we were able to demonstrate that family size contributed to wasting, overweight and obesity but not to stunting. Birth order and family size has been shown to impact growth of children in other studies .
Many low- and middle-income countries have the double burden of malnutrition i.e. coexistence of problems of under nutrition and overweight particularly in the urban setting . Our study also clearly demonstrates the double burden. The children in this region are vulnerable to inadequate prenatal, infant and childhood nutrition. They are also exposed to high fat, high salt, high sugar and energy dense food, which is easily available for those who are economically able. This problem coexists with the lower level of physical activity leading to an increase in obesity while under nutrition remains unsolved .
The strengths of this study are that it has been conducted in a region which has not been explored before and in a large number. The limitations are that it is confined to the Northern part and the results cannot be generalized to the rest of the country. Hence, we recommend that wider scale similar studies are needed to generalize the results to the whole country.