The present study revealed the coexistence of double and triple burden of malnutrition under the same household level in Nepal. We found the prevalence of double and triple burden of malnutrition among mother-child pairs exist 6.59% and 7% respectively. Our study found the prevalence of overweight/obese mother and stunted child (OM/SC) was 8.30% under the same roof. These percentages were slightly higher as compared to the findings from other developing countries in Southeast Asia. The prevalence of overweight/obese mother and stunted child in Bangladesh and India were 4.7% and 3.7% respectively [3, 4]. However, the results from African and Latin American countries showed the prevalence of overweight/obese mother and stunted child varied from 1.8-23% [17, 23]. In 2006, a systematic review done by Kosaka et al., reported the prevalence of overweight/obese mother and the stunted child was only 0.9% in Nepal [13]. Surprisingly, overweight/obese and stunted mother-child pairs have been continuously increased since the last decades. The current study found the prevalence of Overweight/obese mother and wasted child (OM/WC) was 1.26 % and overweight/obese mother and underweight child (OM/UC) was 3.37% in Nepal. This findings is consistent with the study of Bangladesh, where the prevalence of overweight/obese mother and wasted child and overweight/obese mother and underweight children were 1.7% and 3.8% respectively [3].The urbanization in developing countries has an influence on adoption of sedentary life style, consuming energy dense foods and less physical activity that put the individual’s at greater risks of obesity and overweight [24, 25]. Likewise, this result is also similar with the findings from most of the low and middle-income countries where the prevalence of maternal overnutrition and child wasting was varied from 0.3-5.3% [3, 5, 19]. In the current study, the prevalence of overweight/obese mother and anemic child (OM/AC) was 18.87%. In Bangaldesh, Mamun et al., [1] reported the prevalence of overweight mother's pairs with anemic children were 27% which is higher than our study. Likewise, Sarmiento et al., found that the coexistence of overweight/obesity with anemic children was varied from 8.1-27.5% in Colombia [26].
The present study observed the prevalence of DBM in Nepal was 6.59% which is higher than that of the neighboring country Bangladesh. Hauqe et al., [4] study found the maternal over and child undernourished(MOCU) was 4.9% and Das et al., [3] reported the coexistence of overweight/obese mother and underweight or stunted or wasted child (OWOBM/USWC) was 6.3%. However, about 11% of the maternal-child pair's double burden of malnutrition were observed in Indonesia which is higher than most of the South Asian countries [3, 4, 27]. It has been noted that this DBM is associated with the nutrition transition that contributes to a positive energy balance that means the intake of higher energy dense food and less energy expenditure [28]. The increasing trend of overweight/obese mother and undernourished child has reckoned the consequences of maternal child nutrition transition in Nepal. Consequences of nutrition transition may due to household dietary habit. Most of the people are had a tendency to consume calorie dense food with more saturated fat, trans fat and sedentary lifestyle which results in reproductive aged women gaining weight [13, 29]. On the other hand intakes of processed food with low nutrient content leads to child undernourished [3, 23]. Other study reported that the prevalence of overweight/obesity mother and child undernourished is more common in urban areas [20]. This result is consistent with our findings, mothers who lived in urban areas had higher odds of the double burden of malnutrition than urban areas. The reason being most of the people in the urban areas are compelled to buy low costs food as a result of high rises in the living expenses and food prices [30]. Also, most of the households in such a setting have difficulty meeting their basic need and adequate nutritious food [30]. It may benefit the adults however it ruins the child nutritional status [3, 17].
While the adjusted regression model, this study depicts the mother who had short stature was strongly associated with the risk of DBM. This result is consistent with that of Oddo et al., [19] who reported the maternal short stature and mother had older age had higher odds of DBM compared to those normal height and younger age groups. Similarly, this findings is also supported by Ferreira et al., who found the higher BMI was significantly with short stature mother which reflect the vicious cycle of malnutrition that is more prone to the risk of a stunted child [31]. Stunting is the intergenerational phenomenon which transfers from mother to child as well as contributing to small for gestational age that leads to malnourished mother and likely to giving low birth weight and stunted child in first 1000 days of life [5, 32]. Haque et al., and Mamun et al., reported the maternal over and child undernourished were significantly associated with higher income and wealthier family [1, 4] which is consistent with our findings. This result was also validated by other similar studies [5, 11, 33]. Similarly, the current study found that mothers who had wealth status were positively associated with DBM. This is because those in the wealthy family may have increased intake of energy dense food such as processed food trans-fat and sedentary lifestyle [19]. Moreover, our study also found that mothers from the lowest wealth status were likely to be protective against the maternal over and child undernourished. The findings are parallel to the results of the previous study conducted in Bangladesh and Indonesia [19]. Our result revealed that mothers who had an older age group (26- 49 years) were found to be a higher risk of double burden of malnutrition. This result is consistent with Haque et al., and Wong CY et al., who suggested that prevalence of overweight/obesity was higher in the older age groups compared to younger groups [4, 5]. Mothers who attended at least secondary level of education had a higher risk of having a double burden of malnutrition. This findings is supported by Rai A et al., [34] who revealed women had primary/secondary level of education were more likely to be risk of overweight/obesity. However, higher levels of education were protective against maternal child double burden of malnutrition in Indonesia [19]. Other studies suggest that the relationship between education and overweight/obesity is complex and vary from country to country [35]. In developing countries, this association could be partly due to the educational status of women, getting sedentary lifestyle jobs and being unaware of the health consciousness of having overweight/obesity [34]. In case of the mother having poor health and nutritional knowledge, it leads to women being less sensitive to child and her nutritional status in terms of food choices and barriers such as food cost, accessibility, availability, lack of cooking skills [5]. As we found that DBM was more prevalent in mother who attended a lower level of education, therefore, providing nutrition education during pregnancy could bridge this nutritional knowledge gap in Nepal [36].
This study found that only mothers from province number 2 compared with that of province 3 was less likely to be double burden of malnutrition. Al Kibria GM et al., found that mothers from province 2 were less likely to be overweight/obesity. Moreover, the prevalence of overweight/obesity had higher in province number 3 which is Kathmandu, the largest city (and capital) of the country [37].
Further, we intended to examine the triple burden of malnutrition. Maternal overweight/obesity and undernourished child and its associated factors have been explored in most of the Latin American and South Asian countries like Guatemala, Colombia, Brazil, Malaysia, Indonesia, and Bangladesh. However, in mother-child pairs, the coexistence of three forms of malnutrition has not yet examined. Thus, to our knowledge, this study is the first to present in the coexistence of overnutrition mother if there is undernourished child and anemic child under the same household. Present study depicts the coexistence of the triple burden of malnutrition among mother-child pairs was 7% in Nepal. This proportion is slightly higher than the double burden of malnutrition. This could have happened because more than half (53%) of the children aged 6-59 months were still anemic in Nepal [16]. The overall prevalence of anemia among the less than 59 months of children is 54.2% in developing countries [1]. Despite declining undernourished in children, micronutrient deficiency anemia remains one of the most intractable public health problem in South Asia [38]. The plausible explanation for the phenomenon of TBM has not been examined clearly. However, a possible reason could be suggested by various studies that the overweight/obesity mother is more risk factor for being anemia in their offspring. They found impaired iron transfer to the fetus among obese mother and resulting in lower serum iron as well as transferrin saturation in cord blood as compared to normal weight mother thus overweight/obese during pregnancy was positively associated with poorer iron status in the child [39, 40]. It could be happened due to the upregulation of hepcidin under proinflammatory conditions in overweight/obese mothers that lead to impaired iron transfer to the placenta resulting iron deficiency in the newborn [39].
Our study had some limitations, first, the study design was cross-sectional in nature, which could not establish the causal pathway of the association between the predictors and explanatory variables. To find out the causal relationship between the risk factor and different forms of malnutrition, rigorous analytical research is needed. Second, dietary intake of mother and children were not assessed. Likewise, data on the outcome measure of maternal overweight/obesity were not available such as dietary intake, physical activity level, health, and nutrition status during pregnancy. Third, the nutritional status of the mother was assessed using BMI only. BMI method is less accurate than other methods to assess the type of overweight/obesity, such as waist-hip ratio, bioelectrical impedance technique, skinfold thickness, and DEXA methods. Although, these other methods are less feasible to use in study with a wider sample due to expensive. Finally, the operational definition and prior literature for the triple burden of malnutrition are lacking.
Despite these limitations, our study had some strength, we use of population-based nationally representative samples. So our sample size is considerably large which provided reliable results. This study provided information on overweight/obese mother and undernourished child as well as micronutrient deficiency anemia with associated risk factor among mother-child pairs in the same household. These findings can provide relevant information and foundation to establish national nutrition intervention program in Nepal.